Journal of Advanced Clinical and Research Insights

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Temporomandibular joint disorders - Part I
  JCRI
REVIEW ARTICLE
Temporomandibular joint disorders - Part I
Sushant A. Pai1, Shruti R. Poojari1, Keerthi Ramachandra1, Sajeev Bhaskaran2, Mangala Jyothi1
1Department of Prosthodontics Including Crown and Bridge, Sri Rajiv Gandhi College of Dental Science and Hospital, Bengaluru, Karnataka, India
2Practicing Endodontist, Bengaluru, Karnataka, India
Correspondence: Dr. Shruti R. Poojari, Department of Prosthodontics Including Crown and Bridge, Sri Rajiv Gandhi College of Dental Science and Hospital, Bengaluru, Karnataka, India.
E-mail: shrutipoojari40@gmail.com
Received: 14 December 2018 ;
Accepted: 22 January 2019
doi: 10.15713/ins.jcri.248
 
ABSTRACT
The terminology "temporomandibular disorder" (TMD) covers a group of conditions. A lot of attempts have been made to categorize TMD, but all have shortfalls. Some classify by frequency of presentation, some by etiology, and some by anatomy. However, there is substantial overlap in classification system as they are not clinically suitable. Therefore, not even one system persuades all the criteria. TMD is a wide-ranging collection of clinical problems that involve the muscle of mastication, the temporomandibular joint, surrounding bone and soft tissue components, or at times combinations of all of them. Any factor that affects one part of the system is likely to have impact on the other parts also, so it is essential to avoid blind side when we have to consider likely signs and symptoms of a TMD. About 20-30% of the adult populations are affected to some degree; it is predominately a condition of young and middle-aged adults, rather than of children or the elderly, and is approximately twice as common in women as in men. TMD is the second most common non-dental origin orofacial pain, but at the same time, the recurrence of other symptoms such as earache, headache, neuralgia, and tooth pain, which can be related to the TMD or be present as secondary findings to be assessed in the differential diagnosis process.
Keywords: Epidemiology, temporomandibular disorders, treatment
How to cite this article: Pai SA, Poojari SR, Ramachandra K,Bhaskaran S, Jyothi M. Temporomandibular JointDisorders - Part I. J Adv Clin Res Insights 2019;6:6-10.
 
 

Introduction

Temporomandibular joint (TMJ) disorders are any disorder that affects or affected by deformity, disease, misalignment, or dysfunction of the temporomandibular articulation. This includes occlusal deflection of the TMJ and the associated responses in the musculature.

Research diagnostic criteria (RDC) defined temporomandibular Disorders (TMD) as - A collective term describing a group of condition affecting the TMJ, the masticatory musculature, or both.

The definition for TMD that was presented by the National Institute of Health Technology Assessment Conference on Management of TMD (1996) illustrates the terminology problem that must be corrected:

Depending on the practitioner and the diagnostic methodology, the term TMD has been used to characterize a wide range of conditions diversely presented as pain in the face or the jaw joint area, limited mouth opening, closed or open lock of the TMJ, abnormal occlusal wear, clicking or popping sounds in the jaw joints, and other complaints."[1]

Terminology
  • Functional disturbances of the masticatory system have been known by a variety of terminology. In 1934, James Costendescribed a group of symptoms centering on the ear and TMJ. Due to his work, the term Costen syndrome developed.

 
  • In 1959, Shore introduced the term TMJ dysfunction syndrome.
  • Functional TMJ disturbances coined by Ramfjord and Ash.
  • Certain terms described etiologic factors such as occlusomandibular disturbance and myoarthropathy of the TMJ.
  • Stressed pain, such as pain-dysfunction syndrome, myofascial pain-dysfunction syndrome, and TM pain-dysfunction syndrome.
  • Bell suggested the term TM disorders.
  • American Dental Association adopted the term temporomandibulardisorders or TMD.[2]

Epidemiology

Patients who have temporomandibular problems are in a broad age range with a peak occurrence between 20 and 40 years of age. TMD symptoms are more prevalent in women as compared to men; women tend to develop TMD during their premenopausal years. TMD occurrence is not clear entirely; however, few have suggested the influence of hormone, high levels of estrogen have been found in patients.[3]

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Etiology
  • Parafunctional habits
  • Emotional distress
  • Trauma due to blows or impacts which can be acute
  • Trauma caused by hyperextension
  • Occlusal factors
  • Deep pain input.

Parafunctional habits

Diurnal
  • Clenching
  • Grinding
  • Cheek and tongue biting
  • Occupational habits.

Nocturnal
  • Clenching
  • Bruxism.

Emotional distress

Emotional stress activates the hypothalamus and reticularsystem as a result of which there is increase in gamma efferentactivity due to which there is contraction of intrafusal fibers thatcause reflex contraction and increase in tonicity in muscle.

Trauma

Microtrauma

Small forces constantly applied to structure over an extendedcourse of time.
For example, bruxism/clenching.

Macrotrauma

Sudden traumatic or forceful blow that causes structuralalteration.
e.g.: Blow on the face.

Direct trauma
  • Intubation procedures
  • Third molar surgeries
  • Long dental appointments
  • Yawning.

Indirect trauma
  • Injuries that may occur to TMJ secondary to sudden force
  • Cervical flexion-extension injuries (Whiplash injuries).

Deep pain input

There is Central excitement of the brainstem which producesmuscle response known as protective co- contraction (body'sresponse to injury or threat of injury). There is a functionaldisorder of masticatory system; two symptoms are seen: Painand dysfunction.
For example, toothache, earache, and cervical pain.

 
Classifications

Diagnostic classification of TMDs (Burket's 12th edition)[4]

Cranial bones (including the mandible)

1. Congenital and developmental disorders
  • Aplasia
  • Hypoplasia
  • Hyperplasia
  • Dysplasia.

2. Acquired disorders
  • Neoplasia
  • Fracture.

TMJ disorders
  • Deviation in form
  • Disk displacement
  • Dislocation
  • Inflammatory conditions (synovitis, capsulitis)
  • Arthritides (osteoarthritis, polyarthritis)
  • Ankylosis (fibrous, bony).

Masticatory muscles disorder
  • Myofascial pain disorders
  • Myositis
  • Spasm
  • Protective splinting
  • Contracture.

Classification System for Diagnosing TMDs (Okeson
7th Edition)[2]


Masticatory muscle disorder
  • Protective cocontraction
  • Local muscle soreness
  • Myofascial pain
  • Myospasm
  • Centrally mediated myalgia.

Chronic mandibular hypomobility

A. Ankylosis
  • Fibrous
  • Bony.

B. Muscle contracture
  • Myostatic
  • Myofibrotic.
C. Coronoid impedance.

TMJ disorders

Derangement of the condyle-disc complex
  • Disc displacements
  • Disc dislocation with reduction
  • Disc dislocation without reduction.

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Structural incompatibility of the articular surfaces
1. Deviation in form
  • Disc
  • Condyle
  • Fossa.

2. Adhesions
  • Disc to condyle
  • Disc to fossa.

3. Subluxation (hypermobility)
4. Spontaneous dislocation.

Inflammatory disorders of the TMJ
  1. Synovitis/capsulitis
  2. Retrodiscitis
  3. Arthritides
  • Osteoarthritis
  • Osteoarthrosis
  • Polyarthritis.

4. Inflammatory disorders of associated structures
  • Temporal tendonitis
  • Stylomandibular ligament inflammation.

Dr. Mark Piper's classification
  1. Normal
  2. Ligaments or cartilage damage
  3. Partial disc subluxation, with reduction
  4. Partial disc subluxation, non-reducing
  5. Complete disc dislocation, with reduction
  6. Complete disc dislocation, non-reducing
  7. No disc, bone to bone - Adapting
  8. No disc, bone to bone - Adapted.

Examination of TMD[1]

I. The chief complaint (there may be more than one)
A. Location of the pain
B. Onset of the pain
  • Associated with other factors
  • Progression.
C. Characteristics of the pain
1. Quality of the pain
2. Behavior of the pain
  • Temporal
  • Duration
  • Localization.
3. Intensity of the pain
4. Flow of the pain

D. Aggravating and elevating factors
  1. Function and parafunction
  2. Physical modalities
  3. Medications
  4. Emotional stress
  5. Sleep disturbances.

 
E. Past consultations and/or treatments
F. Relationship to other pain complaints
II. Medical history
III. Review of systems
IV. Psychological assessment

Diagnosis

TMD is categorized into articular and non-articular disorders,which is known as extracapsular and intracapsular conditions.Majority non-articular disorders are present as myofascial painrelated to the masticatory muscles. Indeed, >50% of TMJ disorderis myofascial pain. Chronic conditions such as fibromyalgia,muscle strain, and myopathies come under non-articular disorders.A focused history and physical examination are needed fordiagnosis of TMJ disorder. Pain and restricted range of movementare common symptoms of TMJ disorder. Radiographic studiescan also be used as adscititious diagnostic tools. Dental problemsdue to referred pain can be ruled out using periapical radiographs.Detailed imaging of bony structures of the joint can be obtainedfrom cone-beam computed tomography scans and panoramicradiographs. Examination of the disk position and morphologyis done using magnetic resonance imaging (MRI) which is a goldstandard modality; it may also show degenerative bony changes.Along with MRI findings, we should combine patient's clinicalpresentation, signs and symptoms along with TMJ imaging at thetime of a treatment planning.[3,5]

Myofunctional Pain of Masticatory Muscles

Also known as masticatory myalgesia syndrome, TMJ paindysfunction syndrome. Myofascial pain and dysfunction istheorized to begin from muscle spasm caused by over extensionof muscle, muscular over contraction and muscle fatigue, chronicoral habits like clenching, bruxism or other parafunctional habits.The result is strain in muscles of mastication, pain, spasm, andlimitation in functions. Emotional stress also predisposes toclenching and bruxism that causes myofascial pain.

Symptoms consist of chronic pain in muscles of mastication,pain in the ears, neck, and head which radiates tenderness in themuscle, clicking noise in TMJ, and limitation of movements inthe jaw which deviates on opening.[4,6]

Treatment
  • Drugs - aspirin, ibuprofen, and amitriptyline
  • Occlusal splint
  • Physiotherapeutic modalities - heat application, cryotherapy,and transcutaneous electrical nerve stimulation.[6]

Ankylosis

It is a Greek terminology meaning "stiff joint: Hypomobilityto immobility of the joint can lead to inability to open themouth from partial to complete. The definite cause of ankylosisof TMJ is unknown. Two main factors predisposing to theankylosis are trauma and infection in or around the region.In 1968, Topazian reported that 26-75% of cases of TMJankylosis are seen following trauma, while 44-68% are seendue to infection.[7]

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Etiology
  • Abnormal I/U development
  • Birth injury
  • Trauma to the chin
  • Malunion of condylar fracture
  • Injuries associated to malar-zygomatic compound
  • Congenital syphilis
  • Primary inflammation of the joint
  • Metastatic malignancies
  • Inflammation secondary to radiation.

Types of ankylosis

1. False ankylosis
  • Extra-articular
  • Fibrous
  • Bilateral
  • Partial.
2. True ankylosis
  • Intra-articular
  • Bony
  • Unilateral
  • Complete.

Unilateral ankylosis
  • Chin deviates toward the affected side
  • Affected side is foreshortened
  • Lack of contour is seen on the affected side
  • Ramus and body in the ankylosed side is underdeveloped
  • Presence of antegonial notch
  • Malocclusion and tilting of lower incisor and posteriorcrossbite.

Bilateral ankylosis
  • Inability to open mouth
  • Failure of development of the lower jaw
  • Antegonial notch well defined
  • Mandible is symmetrical but micrognathic. Patient developstypical "bird face" deformity with receding chin
  • Severe malocclusion.

Management of TMJ ankylosis

Treatment of TMJ ankylosis is always surgical.
Objective: The objective of this study was to -
  • Establish movements in the joints and functions of the jaw.
  • Prevent relapse.
  • Restore occlusion and appearances.

 
The number of techniques has been advocated by differentsurgeons. Critical analysis of all filters only to three basicmethods:
  • Condylectomy
  • Gap arthroplasty
  • Interpositional arthroplasty.[7]

Traumatic Disturbances

This includes luxation and subluxation, ankylosis, and fractureof condyle. Luxation and subluxation are when dislocationoccurs when condylar head moves anteriorly into such aposition that it cannot come back voluntarily to its normalposition. The etiological factor is traumatic injuries or yawningor opening the mouth too wide which will cause sudden lockingand immobilization of jaws when mouth is opened. Sometimes,mouth cannot be closed. It can be treated by relaxation ofmuscles and moving the mandible to its position by exertinginferior and posterior pressure of thumbs in the mandibularmolar region.[2,6]

Developmental Disturbances

This includes aplasia, hypoplasia, and hyperplasia of mandibularcondyle.

Aplasia occurs when mandibular condyle fails to develop, itcan be unilateral or bilateral which results in facial asymmetry,occlusion and mastication are altered, mandible shifts towardthe affected side, whereas in bilateral cases, mandibular shift isnot present. It can be treated by osteoplasty; malocclusion iscorrected by orthodontic appliances and cosmetic surgery forfacial deformity.

Hypoplasia is underdeveloped or defective formationof condyle. It may be congenital or acquired causing facialasymmetry in unilateral cases, in mild disturbance, there is slightmandibular shifting from midline. It can be treated by cartilageor bone transplants proceeded by unilateral or bilateral slidingosteotomy.

Hyperplasia generally occurs after puberty and is completedby 18-25 years of age, it is unilateral enlargement of condylecaused by mild chronic inflammation as a result of whichhere is unilateral slowly progressive elongation of the faceand deviation of the chin away from affected side, severemalocclusion is seen. This can be treated by resection of thecondyle.[2,6]

Conclusion

A patient suffering from TMD can have symptoms, in anycombination, which may consist of alteration and restrictionin mandibular movement, pain in facial, preauricular musclewhich may worsen with function, crepitation or clicking ofthe joint, unexplained tooth pain, and chronic daily headache.The basic necessity for successful occlusal treatment is stableand comfortable TMJ. This understanding of the TMJ is thefoundation to diagnosis and treatment of almost everything adentist does.

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References
  1. Dawson PE. Functional Occlusion from TMJ to Smile Design. StLouis: Elsevier; 2007.
  2. Okeson JP. Management of Temporomandibular Disorders andOcclusion. 7th ed. St Louis: Elsevier; 2013.
  3. Liu F, Steinkeler A. Epidemiology, diagnosis, and treatmentof temporomandibular disorders. Dent Clin North Am2013;57:465-79.

 
  1. Glick M. Burket's Oral Medicine. 12th ed. USA: People's MedicalPublishing House; 2015.
  2. Gray R, Al-Ani Z. Temporomandibular Disorders a ProblemBased Approach. 1st ed. Ames, USA: Wiley Blackwell; 2011.
  3. Malik NA. Textbook of Oral and Maxillofacial Surgery. 2nd ed.New Delhi: Jaypee Brothers; 2008.
  4. Kaban LB, Perrott DH, Fisher K. A protocol for managementof temporomandibular joint ankylosis. J Oral Maxillofac Surg1990;48:1145-51.

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