Journal of Advanced Clinical and Research Insights

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Temporomandibular joint disorders - Part II
Temporomandibular joint disorders - Part II
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.
Received: 24 December 2018 ;
Accepted: 26 January 2019
doi: 10.15713/ins.jcri.249
This article is the continuation of temporomandibular joint (TMJ) disorders - Part I. This article focuses on the intracapsular disorders of the TMJ and the most common types that we as a dentistencounter. The condition of the intracapsular structure of TMJ affects the position of the TMJs; it also affects the occlusal relation.
Keywords: Epidemiology, intracapsular disorders of temporomandibular joint, temporomandibular disorders, temporomandibular disorders, treatment
How to cite this article: Pai SA, Poojari SR, Ramachandra K,Bhaskaran S, Jyothi M. Temporomandibular JointDisorders - Part II. J Adv Clin Res Insights 2019;6:11-13.


Intracapsular disorder of the temporomandibular joint

Any disease, deformation, or disorder that involves the tissues within the capsule of the TMJ is known as intracapsular disorder.[1]


Piper's classification

Piper's classification for intracapsular temporomandibular disorders (TMDs) relates specific structural disorders to the progressive patterns that routinely occur as TMJs go through stages from health to severe degeneration.

There are seven structural elements to evaluate pain:
  1. Disk alignment
  2. Disk shape
  3. Ligament
  4. Joint space
  5. Muscle
  6. Bone surface
  7. Pain.

Disk alignment

Normal disk alignment positions the disk on the condyle so that all the compressive forces are directed through its avascular, non-innervated bearing area. Variations in the disk alignment have major implications related to the signs and symptoms of TMD. It is important to analyze disk alignment at both the medial and lateral poles of each condyle.

Disk shape

Determining whether the disk is elongated, folded, or deformed into a compressed mass can explain variations in joint signs and symptoms and is often a determinant in treatment planning and prognosis.


Laxity of the ligaments makes disk derangement possible if muscle incoordination is allowed to exert tensive forces on the disk. If the disk is not deformed, then a peaceful neuromusculature can be maintained, and laxity of the ligament is not itself a single cause for disk displacement.

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Pai, et al. Temporomandibular joint disorders - Part II

Joint space

The "space" between the condyle and fossa is not a void. It is theresult of radiolucency of the disk and appears as a dark space onthe film that represents the thickness of the disk. If the disk isdisplaced, the condyle moves higher into the fossa and the spaceis diminished.


There will always be a reason for any muscle to be hyperactive, andthe most common primary causes in the masticatory musculaturewill be either trauma or some form of structural disharmony ordeflective occlusal interference. Even when emotional stresslevels are high or clenching and bruxing is evident, there willalmost always be a structural muscle in coordination.

Bone surface

Signs may range from mild surface changes on the condyle andeminence to complete destruction of the condyle.


Need for analyzing the type, location, and severity of pain shouldbe known. Important aspect of this analysis is to determinewhether intracapsular structures are the source of any, all, ornone of the pain. Compressive loading of the joints in differentjaw positions is the most effective way to determine this.[1]

Intracapsular disorders (articular disk disorder)

Articular disk displacement is an abnormal relationship betweenthe following:
  • The disk
  • The mandibular condyle
  • Articular eminence.

Caused by the stretching or tearing between glenoid fossa andattachment of the disk of the condyle. Articular disk disorder isdivided into stages on the basis of signs and symptoms combinedwith the result of imaging studies:
  1. Articular disk disorder with reduction
  2. Articular disk disorder with intermittent locking
  3. Articular disk disorder without reduction (closed lock).

Articular disk disorder with reduction (clicking joint)

It occurs due to the loosening of articular disk as it tends toelongate or tear or restrain the ligaments and has displacedfrom its original position on top of the condyle. Usually, pain isduring mandibular movements, and it is noticeable at the timeof click.

  1. Flat plane stabilization splints
  2. Anterior positioning appliances - introduced by Farrar, itcreates an occlusal relationship that needs the mandible to bemaintained in forward position.

Articular disk disorder without reduction (closed lock)

It occurs more frequently in patients with clicking joints whichstarts with the progression of intermittent brief locking and endsup in permanent locking. Opening of the mandibular is limitedwhen there is interference between the disk and the normaltranslation of the condyle along the glenoid fossa. There is alsolimited lateral movement along with pain.


a) Manual manipulation
b) Exercise program
c) Flat plane occlusal stabilization appliance
d) Anti-inflammatory drugs.


a) Arthrocentesis
b) Arthroscopy.

Posterior disk displacement (open lock)

During opening, the condyle slips over the anterior rim of thedisk with the disk being caught and brought backward in theabnormal relation to the condyle when the mouth is closed. Inthis condition, there is sudden inability to bring the upper andlower teeth together in maximal occlusion. There are restrictedlateral movements along with pain in the affected side, whereasthere is no restriction of mouth opening.


Recommended treatment for symptomatic articular disk
  • Splint therapy
  • Manual manipulation and other form of physical therapy
  • Anti-inflammatory drugs
  • Arthrocentesis
  • Arthroplasty
  • Vertical Ramus osteotomy.[2,3]

Degenerative joint disorder (osteoarthritis and
hypertrophic arthritis)

It is primarily a disorder of articular cartilage and subchondralbone, with secondary inflammation of synovial membrane. Itis related to aging and common in joint subjected to stress andstrain. Osteoarthritis can take place at any age, although, as theage increases, the chances of osteoarthritis also increase. A studyconducted on the age group of 73-75 years found that 70% ofthe subjects have radiographic proof of osteoarthritis. About9.6% of men and 18% of women above the age of 60 years havesymptomatic osteoarthritis.

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Temporomandibular joint disorders - Part II Pai, et al.

Symptoms include inflammation joint effusions, clicking,snapping or unilateral pain over the condyle, crepitus, limitedmouth opening, in certain cases there may be destruction of thedisc.[3,4]


The diagnosis is started with a organized review of a history ofthe patient and detailed physical examination. This informationshould be included with preliminary radiographic evidenceto conclude a differential diagnosis. Since the clinician has adifferential diagnosis, the diagnosis may be confirmed throughsuitable imaging studies along with necessary clinical laboratorystudies. This whole process of completing the different aspects issignificant for the successful management of these patients.



Patient education and self-management include counseling ofthe patient and education about the natural path of the disease.Modification in the activity consists of patient education onsoft diet, avoiding extreme opening of the mouth and avoidingchewing gum along with modification of habits. The employactive and passive movement of the jaw, manual therapytechniques, rectification of posture of the body, and relaxationtechniques should also be suggested. Dental procedures suchas orthodontic treatment, rehabilitation of the mouth, andfixed partial denture must be avoided in the active phase of thedisease. In this phase of the disease, reversible procedures andstabilization procedures must be carried out to present finestresults.


Pharmacological treatment modalities comprises ofacetaminophen, cyclooxygenase-2 selective and non-selectiveoral NSAIDs, topical NSAIDs and capsaicin, intra-articularinjections of corticosteroids and hyaluronates, glucosamine andchondroitin sulphate for relief of the symptoms; glucosaminesulphate, chondroitin sulphate and diacerein are used for theirstructure modifying effects and utilization of opioid analgesics forthe management of refractory pain. NSAIDs are tremendouslyhelpful for treating patients with TMJ Osteoarthritis as they havea dual effect of reducing pain and reducing inflammation.[4]


A patient suffering from TMDs can have symptoms, in anycombination, which may consist of alteration and restriction inmandibular movement, pain in facial and preauricular musclewhich may worsen with function, crepitation or clicking ofthe joint, unexplained tooth pain, and chronic daily headache.The first 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.

  1. Dawson PE. Functional Occlusion from TMJ to Smile Design.St Louis: Elsevier; 2007.
  2. Okeson JP. Management of Temporomandibular Disorders andOcclusion. 7th ed. St Louis: Elsevier; 2013.
  3. Malik NA. Textbook of Oral and Maxillofacial Surgery. 2nd ed.New Delhi: Jaypee Brothers; 2008.
  4. Kalladka M, Quek S, Heir G, Eliav E, Mupparapu M,Viswanath A, et al. Temporomandibular joint osteoarthritis:Diagnosis and long-term conservative management: A topicreview. J Indian Prosthodont Soc 2014;14:6-15.

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