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The term TMJ is an abbreviation for two of the facial joints known as the Tempormandibular Joints. So we can fully understand the causes and the pathology associated with TMJ Dysfunction, we can look at the anatomy of the TMJ itself. In a normal and healthy joint, the disc is concave on the top and bottom, and it acts as a lubricated protective barrier between the head of the mandible or jaw joint (condyle) and the joint space, also known as the fossa.
When you open your jaw, the disc should stay in place and the head of the mandible (condyle) first rotates, then translates (moves forward and down) with help of the lateral pterygoid muscle. In some cases the posterior ligament gets over-stretched and the disc sits in front of the joint head. Note how the retrodiscal tissues are stretched out and the bi-concave shape of the disc is anteriorly displaced. Depending on the trauma and the level of TMJ Dysfunction, the disc can be anteriorly displaced (in front), or it can be displaced to the side (medial or inside; lateral or outside).
Generally speaking, dentists are the most knowledgeable professionals to treat the TMJ and TMD. Science, Technology and Medicine open access publisher.Publish, read and share novel research.
Diagnosis and Management of Temporomandibular DisordersFina Navi1, Mohammad Hosein Kalantar Motamedi3, Koroush Taheri Talesh2, Esshagh Lasemi2 and Zahra Nematollahi4[1] Scientific Faculty, Department of Oral and Maxillofacial Surgery, Azad University of Medical Sciences, Tehran, Iran[2] Department of Oral and Maxillofacial Surgery, Azad University of Medical Sciences, Tehran, Iran[3] Department of Oral and Maxillofacial Surgery, Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran[4] Private Practice Dentistry, Tehran, Iran1.
Include: bony changes in subarticular bone of condyle and fossa, sclerosis, subarticular cysts, osteophyte, low density and roughness. Is Tonsillectomy a Possible Treatment for IgA Nephropathy from Randomized Controlled Trial (RCT)?
Temporomandibular disorders, or TMDs, is a collective term that has been used traditionally to describe multiple disorders. The general presenting complaints of the temporomandibular disorders include facial pain, earache, and headache. Each individual joint consists of the condylar process of the mandible, which is housed within the glenoid fossa of the squamous portion of the temporal bone. The degree of condylar movement is governed by the limiting actions of the joint capsule, the articular disk, and the joint ligaments. The TMJ is susceptible to the same conditions that affect other joints in the body such as congenital and developmental anomalies, traumatic injuries, dislocations, internal derangements of the articular disk, ankylosis, various arthritic conditions, and, rarely, neoplastic diseases (Table 94-1). Because the condyle has an important role in mandibular growth, congenital and developmental anomalies such as condylar agenesis, condylar hypoplasia, or condylar hyperplasia can produce severe facial deformity. The condyloid process and, more specifically, the condylar neck is one of the most frequent sites of fracture after trauma to the mandible. Dislocation occurs when the hypermobile mandible becomes fixed in an open position with no or only the most posterior teeth contacting. Dislocation that is chronic can be treated by injection of a sclerosing agent into the TMJ capsule and lateral ligament to produce scarring of the stretched tissues,12 capsulorrhaphy, lateral pterygoid myotomy, temporal myotomy, or condylectomy.13 Decision as to the appropriate surgical procedure is based on the etiology, severity, and persistence of the dislocation. Intracapsular disorders of the TMJ include the following: (1) anterior disk displacement with reduction on opening the mouth, (2) anterior disk displacement without reduction, and (3) degenerative joint disease. Anterior disk displacement with reduction is typically characterized by clicking or popping sounds on mouth opening (Fig. Acutely displaced disks without reduction can often be successfully treated by manual manipulation of the mandible with coincident reduction of the disk. TemporoMandibular Dysfunction (TMD) includes the jaw joint (TMJ), muscles, tendons, ligaments and nerves.
In IMAGE 5, as the jaw opens wider, the ligament stretches to its limit and the disc slips onto the jaw joint. Closed Lock is the termed used for a TMJ disorder in which the disc is off the jaw joint and the disc does not slip back onto the jaw joint when opening ones mouth. Opening of the mouth can occur but it is limited, usually limited to half of its normal opening.
In IMAGE 6, the upper & lower teeth are together and the disc is off the jaw joint (condyle). In IMAGE 7, as the jaw is opened, the disc does not slip onto the jaw joint. As a result, the disc limits the jaw joint from advancing forward which prevents the jaw from fully opening. The disc can be reduced (placed back onto the jaw joint) by a painless joint injection, especially if treated early after onset.
If treatment is not done, degeneration of the TMJ may occur causing more pain and dental problems.
In IMAGE 8, TMJ disorders can progress to degeneration of the joint and surrounding tissues. TMJ Dysfunction is any of the pathologies of the face that are associated with the two TMJs. If there is TMJ dysfunction present, the disc sits in a number of places other than snug in between the condyle and fossa.
TMJ dysfunction occurs because when you open the jaw, the displaced disc "clicks" or "pops" back in place. Mandibular dislocation - the position of the condyle head is in front of the articular eminence. IntroductionTemporomandibular disorder (TMD) is one of the most common disorders in the maxillofacial region which usually presents with pain, unusual sounds, discomfort in chewing and locking of the jaw.
Measure range of motion of the mandible or opening and right and left lateral excursions ( note any uncoordination in the movement)2.
These include both intracapsular disorders, or true abnormalities of the temporomandibular joint (TMJ), and muscular disorders, or myofascial pain dysfunction syndrome (MPD). Therefore it is important for otolaryngologists to be familiar with the diagnosis and treatment of these various conditions. The anterior wall of the glenoid fossa is formed by the articular eminence, which is the articulating counterpart to the condylar process. The disk is a unique structure that is concavo-convex on its superior surface and concave on its inferior surface, where it contacts the convex condylar head. The primary ligaments of the TMJ are the lateral, sphenomandibular, and stylomandibular ligaments.
Although many of these conditions are treated in the same manner as in other joints, the previously described anatomic and functional differences of the TMJ often require some variations of therapy. It is important to diagnose and treat these conditions early in order to limit the degree of mandibular, as well as compensating, facial deformity.
Condylar or subcondylar fractures will usually produce preauricular pain and tenderness, difficulty in opening the mouth, and malocclusion.
Nondisplaced fractures with minimal dysfunction may be treated with soft diet and guiding elastics.
Acute dislocation occurs when the condyle translates anterior to the articular eminence and becomes locked in that position. This may be a single, macrotraumatic event or, more likely, frequent episodes of microtrauma that occur over a prolonged period. In chronic conditions, manual reduction is much less likely to lead to satisfactory reduction of the disk. The TMJ connects the mandible (lower jawbone) to the temporal bone of the skull in front of the ear.
As a result, many people tend to think their TMJ condition is getting better, but in fact it is becoming worse. Busciglio can significantly reduce or eliminate your pain in two to four weeks after therapy is initiated. You do not need to suffer from TMJ or TMD symptoms any longer.
While both are statistically significant for identifying arthralgia in patients with ADD, the trend favors the alternative protocol. Sometimes the click or pop is audible and can be heard, but at early stages or "partial disc displacement," the disc is not fully off of the condyle and often times there is no pain or uncomfortable feeling.
TMD patients comprise a considerable proportion of patients seeking treatment; early diagnosis is important because it is proven that acute TMD responds well to treatment in contrast to chronic TMD. Additionally, some disorders have not been considered under the umbrella of TMD but either directly or indirectly affect the structures of the TMJ. Much of the difficulty encountered in the treatment of TMDs relates to the failure to distinguish between these disorders and other causes of head and facial pain because of the similarity of the signs and symptoms with which they present. Because the mandible is hinged at both ends, each joint is incapable of independent movement. The articulating surfaces are lined with fibrous connective tissue and are enclosed by a fibrous capsule.
The presence of the articular disk divides the joint into two distinct compartments and contributes to the dual action of this ginglymoarthrodial joint. The relationship of the articulating components of the joints is also influenced by the presence of the teeth. However, examination of the current concepts regarding the diagnosis, preparatory treatment, and surgical therapy of the dentofacial deformities is beyond the scope of the current discussion.
Unilateral fracture will produce jaw deviation to the affected side on attempted mouth opening. Moderate changes in occlusion or function may require short-term maxillomandibular fixation.
It is treated with manual reduction by applying downward pressure on the posterior mandible while placing upward and backward pressure on the chin. Malignant tumors, which are even more uncommon, include fibrosarcoma, chondrosarcoma, and multiple myeloma. In the nonreducing joint, forward translation of the condyle on mouth opening forces the disk anteriorly, causing it to become a physical impediment to further opening.
Without this cushion, the two bones will wear each other down causing degeneration of the bones and pain. Clicking or popping of the jaw joint can last as little as a week to many years before the disorder may move on to the next stage of the jaw locking closed. True diagnosis and treatment of TMD can be difficult, as these patients often suffer from some other disorder at the same time. Moreover, it is noticeable that, growth-developmental disorders include aplasia, hypoplasia, hyperplasia and dysplasia can lead to TMJ problems.Aplasia is defective growth of skull or mandible bones.
Individuals suffering from osteoarthritis usually have unilateral pain which becomes worsened in mandibular movements and also in late afternoon and night. Examples of these disorders are congenital and developmental deformities, trauma, and neoplastic disease.
The emphasis in this chapter is on the diagnosis of TMDs, with a subsequent discussion of what is known about the etiology of the various conditions, forming the basis for a rational approach to therapy. This is clinically important because dysfunction in one joint can adversely affect the function of the contralateral joint, producing bilateral symptoms. The inferior compartment, or inferior joint space, allows for purely anterior and posterior rotational movement between the condyle and disk.
When the mouth is in an open position, the degree and direction of movement of the joints are influenced by the components discussed earlier. Bilateral fractures frequently produce an anterior open bite due to loss of structural support in the ascending ramus. In situations where the malposed segment is significantly displaced or interferes with jaw function, there are no occluding teeth on the involved side, or the condyloid processes are fractured bilaterally and grossly displaced, open reduction should be performed.11 Additional considerations for open reduction are the inability to perform maxillomandibular fixation and the presence of concomitant fractures in the mandible, maxilla, or midface. This manipulation is supplemented by the use of local anesthesia, intravenous sedation, or general anesthesia. Direct extension of neoplasms from adjoining tissues and metastasis from distant neoplasms have been reported. Patients who present with anterior disk displacement with reduction generally exhibit a normal range of mandibular motion.
The maximum interincisal opening (MIO) is generally only 25 to 30 mm, and the mandible deviates toward the affected joint.
Patients who exhibit a chronically nonreducing disk should be initially treated with a stabilization splint in order to reduce the pressure on the retrodiskal tissues produced by masticatory and parafunctional forces. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.AbstractAims. In these cases, a successful treatment is due to true diagnosis of all initiating factors, predisposing and perpetuating factors and treatment of other established disorders. These belong to one group of mandibular anomalies named hemifacial microsomia or first and second brachial arch syndrome. Articular changes may be due to trauma, destructive forces, infection or an idiopathic process (Fig.
The superior joint space allows for translational movement between the disk and the glenoid fossa and articular eminence. However, when the teeth come into contact, this occlusal relationship determines the final position of the condyle with respect to the rest of the joint. Most malignant neoplasms that affect the TMJ are not radiosensitive, so radiotherapy is generally not considered. Lateral excursive movements of the mandible are generally restricted to the contralateral side but not to the ipsilateral side.
When pain is a significant component of this disorder, more aggressive or invasive procedures may be indicated.


An important point is the close relation of intrajoint disorders to disorders of masticatory muscles. These are the most common developmental defects which have no articular fossa or eminence and the patient suffers from hearing problems.
Note excessive occlusal wear , excessive tooth mobility , buccal mucosal lateral tongue scalloping6.
This factor becomes increasingly important in individuals who exhibit occlusal disharmony or parafunctional habits.
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be prescribed for control of pain and inflammation. A clicking or popping sound occurs as the disk returns to its normal position in relation to the condyle. In terms of clinical relevance, the absence of false positives is highly important in determining treatment course, especially in non-life-threatening disorders such as temporomandibular joint dysfunction (TMJD) [6].
Their signs and symptoms are like in osteoarthritis but with completely different etiology. MRIs of the TMJ were obtained with the patient at maximum aperture without pain, the sagittal standard was corrected, and T1 protocol was used for the anatomical study of the TMJ.
All images had been previously diagnosed by an independent evaluator of the study; they were subjected to an evaluation by a second researcher, who was blind to the initial diagnosis.
When pain is present, it is the general determinant of any functional limitation that exists.
The standard protocol for MRI diagnosis of DD, using a 12 o’clock reference position, was compared to an alternative protocol. A Case-Control Study Desplazamiento Discal Anterior y la Cabeza Superior del Músculo Pterigoideo Lateral. Only those images in which there was agreement between the diagnosis of cases and controls were considered. Treatment of these painful joints consists of soft diet, self-limitation of opening, NSAIDS, splint therapy, and physical therapy. During closure, the disk again becomes anteriorly displaced, sometimes accompanied by a second sound (reciprocal click) (E, F).
The alternative protocol involves the functional relationship between the condyle and articular eminence, using a line perpendicular to the posterior slope of the eminence as a reference for disc position.
Many craniofacial anomalies include incomplete growth of cranial and mandibular bones, for example Treacher-Collins syndrome. Clinically, patients have consistent pain becoming severe with movements and opening limitation. The reliability of the measurements of the percentage of the SHLP in the disc were analyzed using the remeasurement method of a random sample (n=15 cases and n=15 controls) and expressed in terms of the correlation coefficient (ICC).
Patients refractive to these conservative modes of therapy may be candidates for more invasive procedures such as arthrocentesis, arthroscopy, or open joint surgery. The disc location was examined using both protocols, and disc diagnoses were compared in their relationship with joint pain. The diagnostic steps and differential diagnosis of TMD and the treatment protocols from supportive treatment, splint therapy and physiotherapy to temporomandibular joint (TMJ) surgeries are explained herein. Hyperplasia is extensive growth of bones in congenital or acquired form which is unilateral in mandibular body, coronoid or condyle and leads to asymmetry. Realistically, the experience of TMJ pain is related to a myriad of causes, and internal derangement would not be expected to be the only one. We hope this chapter can help better understand TMJ disorders, diagnosis and recognition of the signs and symptoms of disorders of the temporomandibular and masticatory system.2. Clinical features are continuous pain, pain on swallowing and limitation in mandibular movements.
Temporomandibular disorder (TMD)TMD is a general term including clinical problems which affect masticatory muscles, TMJ and adjacent structures.
Carlsson, “Clinical findings related to morphologic changes in TMJ autopsy specimens,” Oral Surgery, Oral Medicine, Oral Pathology, vol. The most common sign of TMD is pain in masticatory muscles, or preauricular region and on the TMJ which becomes severe when chewing or upon other mandibular movements. From the benign ones, osteoma, chondroma, osteoblastoma, chondroblastoma, ameloblastoma and synovial chondromatosis (which is common in TMJ) can be named.
Advantages are low price and the possibility of comparing both sides of mandible and fossae.
While the standard method of diagnosis identifies the majority of subjects with arthralgia as having ADD, approximately 30% of its ADD patients are asymptomatic. Malignant tumors such as osteosarcoma, Ewing sarcoma, chondrosarcoma, fibrosarcoma and adenocarcinoma are usually rare. In initial stages, there is no distinctive radiographic sign because changes are in soft tissues. Perhaps such a disc position is a variant of normal and should be considered adaptive rather than dysfunctional.
But after progressing, erosive changes, subchondral cysts, decrease in articular space, bone degeneration and osteoporosis can be seen. Shaefer and Schiffman found that TMJ pressure-pain thresholds (PPTs) differed between asymptomatic TMJ arthralgia subjects with and without disc displacement with only those subjects without a history of disc displacement recording normal pressures [5].
Fractures can result in displacement, damage of joint surfaces, ligaments and disc in combination with bleeding, then adhesion, or joint derangement can be expected. A similar determination of PPTs in this study’s subjects would allow insight into what degree of disc displacement correlates to normal versus mild dysfunction. Masticatory muscle hypertrophy and an unusual facet of occlusal surfaces of the dentition due to excessive mandibular movements such as bruxism or grinding may be present. We analyzed 75 images of patients with anterior displacement and 75 controls with normal relationship between the mandibular head and the articular tubercle also diagnosed by MRI. Nevertheless, because the alternative protocol avoids false positives and is functionally based, it is more rigorous and clinically pertinent. CT does not play an important role in diagnosing disc displacement because it is problematic in showing the disc.
The only relationship with a significant association was found when comparing subjects with a 50% of inserting the disc into the SHLP to those who had higher levels of insertion (50%). It appears that the alternative criteria for determining disc displacement allow a more constructive assessment of TMJ anterior disc displacement.While the results of this study are promising for better understanding the causes of TMJ arthralgia, there are limitations to our investigation. Westesson, “Reliability and validity of imaging diagnosis of temporomandibular joint disorder,” Advances in Dental Research, vol. Any growth or acquired remodeling and anatomic deformation that destroy joint surfaces results in mechanical interference that clinically results in joint noises or clicking during opening and closing. Because our study was retrospective, the imaging protocol for the MRIs could not be controlled. Diagnostic criteria:One of the most important signs of this disorder is deviation of the jaw on mouth opening and closing. Histologically, in progressive stages, there is severe secretion of lymphocytes, plasma cells and lysosomic enzymes with exudates in the joint.
Analyses of differences were made by Fischer's exact test and also were calculated clinical significance (OR, CI = 95%).
The images were collected from a variety of sources which may or may not have used the same techniques in creating the images. Dynamic and functional movement of the disc and condyle can be assessed via fluoroscopy and video in this method. HistoryAfter initial studies in 1934, Costen proposed that patients suffering from auricular pain, pressure and fullness in the ear and swallowing problems (Costen syndrome) improve by occlusion correction.
The only relationship that presented a significant association (OR 5.61) was found when comparing subjects with a percentage of inserting the disc into the SHLP at 50% with those who had higher levels of insertion (50%). Distribution of cases and controls and statistical association for different insertion levels of SHLP in the disc. In the 1960s, the quality of clinical examinations and scientific studies improved; the importance of occlusion in TMD etiology in 1970 was studied.
Our results suggest that the highest percentage of insertion serves as a protective factor for anterior disc displacement, probably due to greater control of neuromuscular activity. As such, the central cut we used to interpret each MRI may not represent a uniform location in the TMJ. Methods including tomography, arthrography, computed tomography (CT) scan and magnetic resonance imaging (MRI) lead to improvements in examination of intracapsular structures.
This could influence results, particularly considering that the disc position in the sagittal plane may be different depending on how medially or laterally in the joint the image is taken (see discussion in Rammelsberg’s study).
Today the information in this field show that patients with orofacial pains may suffer from disorders such as systemic, neuromuscular, vascular, and mental or a combination of disorders associated with TMD; some headway in pain mechanism, neurology, physiology and neuoropharmacology have been made. Different studies demonstrated that TMD treatment has changed based on the diagnosis of the etiology and stage of the disorder. A simple solution would be to perform a reliability study, wherein a sample of the MRIs that were interpreted for ADD is reinterpreted at a later date by the same examiner, and the diagnoses are compared to ensure concordance.Another consideration in interpreting the images at one static point in time is the effect of treatment on the structures of the TMJ.
The disc is anterior to the condyle corrected upon translating (opening) and a click may be heard.
TMJ anatomy Temporomandibular joint is the junction site of the mandibular condyle to skull base or glenoid fossa of the temporal bone. Radiographic findings reveal osteoarthritis changes with erosion, osteoporosis and narrowing of articular space.
This information, together with significant suprasegmental references receiving trigeminal motor neurons responsible for the contraction of motor units of SHLP, seems to have an important role in regulating disc position.
A number of studies have demonstrated alterations in the form and relative position of constituents of the TMJ due to orthopedic forces, for example, the use of functional appliances in orthodontics, which have been shown to influence the jaws by remodeling the condyle and glenoid fossa, repositioning the condyle, and autorotating the mandible [22]. Changes that could appreciably alter disc position include anterior or posterior movement of the condyle and flattening of the articular eminence [23–25].
The part of the disc which is in contact with mandibular condyle bone consists of fibrous connective tissue without any nerve or vessel. These two noises or clicks are named reciprocal which are the results of disc displacement. For example, Wadhawan completed an MRI study demonstrating an initial posterior displacement of the disc during removable functional appliance therapy for class II malocclusion, but noted that the degree of displacement was not consistent with pathological derangement [22].
Furthermore, the disc position returned to the pretreatment location after functional appliance therapy was completed. La inserción media de la CSPT fue 71,14% (DS 14,13) en los controles y 67,80% (SD 16,23) en los casos de grupo.
Many of the studies relating to orthodontics and TMJ structures exhibit such reversal of the TMJ structure alterations over the long term [22–26]. Anderson, “Pressure-pain thresholds and MRI effusions in TMJ arthralgia,” Journal of Dental Research, vol. Therefore, the position of the disc may vary according to the treatment undertaken, and the latter should be taken into consideration when analyzing the anatomy of the TMJ.
Severe trauma plays an important role especially in cases resulting in distraction or ruptured ligaments or capsule (Fig. This study also did not consider the presence or absence of osteoarthritic changes (OA findings) in the TMJ, nor synovitis, both factors which have been at least as well (if not better in the case of synovial tissue proliferation) associated to TMJ arthralgia as is disc displacement [9, 27, 28].In order to address such limitations and advance the insight into TMJD etiology, a prospective investigation of anterior disc displacement would be of great benefit. The possibility of involving TMJ is low but in cases of TMJ involvement, signs are mild and the most important one of them is limitation in mandibular movements, pain, and diffuse stiffness in muscles. Such a study would provide improved standardization of the MRI images and the classification of arthralgia and would allow for more variables to be included, such as the presence of joint inflammation, synovial tissue proliferation, and measures of specific inflammatory mediators [27–30]. Additional variables, in a temporal sequence, could aid in clarifying the effect disc displacement has on joint dysfunction and allow a better correlation of the degree of disk displacement to arthralgia symptoms [31]. A prospective study would offer a view into the evolution of TMJD over time and measure the influence and outcome of different therapies.This investigation demonstrates a functionally and therefore clinically relevant method for diagnosing anterior disc displacement on MRI.
Disc displacement or dislocation without reduction: In this state there is alteration in translating movements and an abnormal relationship remains in opening and closing. Guarda-Nardini, “Agreement between Research Diagnostic Criteria for Temporomandibular Disorders and Magnetic Resonance Diagnoses of Temporomandibular disc displacement in a patient population,” International Journal of Oral and Maxillofacial Surgery, vol. In the posterior part, the disc is attached to a loose connective tissue of nerve and vessels named retrodiscal tissue. Thus, the disc does not return to its correct position and remains dislocated anteriorly without any correction during translating movement.
The percentage of fibers inserted into the disc from SHLP is still debated in the literature; according to Naohara (1989) the percentages of the total muscle and the superior head are 3 and 30%, respectively, while for Bittar et al. In the superior posterior part, it is attached to a connective tissue full of elastic bands named superior retrodiscal layer or bilaminary zone. The term “closed lock” is used to describe this disorder (the jaw is locked and will not open). It is the most common form which occurs between condyle and disc or between disc and fossa. Our protocol recommends utilization of the functional area of the articular eminence for imaging the TMJ by drawing a line perpendicular to the posterior slope of the articular eminence in the TMJ from which to determine anterior disk displacement in a sagital plane.


Treatment of severe temporomandibular joint clicking with botulinum toxin in the lateral pterygoid muscle in two cases of anterior disc displacement.
Below this, there is the inferior retrodiscal layer which connects the inferior border of the posterior edge of the disc to the posterior part of condyle joint surface. In another classification, low mobility disorders are divided into three groups:Trismus because of stiffness of masticatory muscles. Inferior disc layer and superior retrodiscal tissue are made of collagen and elastic fibers, respectively. Psudoankylosis which results from extracapsular causes and leads to reduced mandibular movements. Anteriorly to the disc, superior and inferior adhesions of it connect to the capsular ligament. The normal activity of the SHPL has been associated with anterior displacement of the disc that occurs with the translation of the jaw opening, and then returns to playing the disc with the mandibular head in the closing oral jaw, because the active relaxation fascicles of the SHPL inserts the disc.
Funding support was provided by the Harvard Medical School Office of Enrichment Programs, the Massachusetts General Hospital Oral and Maxillofacial Surgery Department’s Education and Research Fund, and via the University of Minnesota Tissue Implant Registry and Repository (TIRR) in whole or in part with Federal funds from the National Institute of Dental and Craniofacial Research, National Institutes of Health, under Contract no. The most severe form of it is low mobility because of bony adhesion of condyle to glenoid fossa. Between the capsular ligaments, the disc is adherent to fibers of the superior lateral pterygoid muscle.
The most common form of low mobility is trismus from infection, trauma, malocclusion, tumors and mental problems.The most common cause of pseudoankylosis is due to zygomatic arch and condyle fracture. The disc adheres to the capsular ligament, not only anteroposteriorly, but also mediolaterally. This fracture leads to transgression of a part of these structures to articular space and finally, inhibition of condyle movements.
In chronic cases, a history of joint noises and then limitation in mandibular opening is usually present (Fig.4). Adhesion of the coronoid process and hypertrophy around it, or fibrosis of the temporalis muscle, can be considered as other causes of pseudo ankylosis. Keith, “The temporomandibular joint: clinical and surgical aspects,” Neuroimaging Clinics of North America, vol. The superior space is located between the glenoid fossa and superior part of the disc; the inferior disc space lies between the disc and condyle. Internal surfaces of superior and inferior spaces are lined with special endothelial cells which secrete synovial fluid. Following trauma, in children, after 3 to 6 months, mandibular movements become progressively reduced; the most important mechanism after trauma, is bone formation following intracapsular hematoma or intracapsular fracture.
This study was conducted with the informed consent of patients for the acquisition of the images, and the rules of the ethics committee of the Hospital were followed. The examinations were requested by different clinical services for various reasons; images obtained during 2007 were included, excluding those with a history of temporomandibular joint closed-lock, disc adherence, trauma study, or pre- and post-TMJ surgery assessment. During function, forces entering to the joint surfaces lead to movement of this fluid into intrajoint tissues. With a lower percentage, ankylosis occurs after intracapsular inflammations such as rheumatoid arthritis, Still's disease, Marie-Strumpel disease etc. In coronal view, the condyle has a medial and lateral pole; the medial pole is thicker than the lateral one.
Histologic characteristics of the lateral pterygoid muscle insertion to the temporomandibular joint.
Inflammation including synovitis, capsulitis and retrodiscitis often occur following trauma, damage, infection or other joint disorders.
TMD etiologyTMD is considered as a multifactorial disorder and there is no special or individual cause for it.
Synovitis: Wearing of synovial tissue of TMJ can occur after trauma, intracapsular irritation and even unusual function.
Bone deformations, soft tissue metaplasia of TMJ and muscle activity reduction are often adaptive responses to changes.
Clinical features of synovitis are local pain which becomes severe during mandibular movements. Witkamp, “Temporomandibular joint structures: a comparison between anatomic and magnetic resonance findings in a sagittal and an angulated plane,” Journal of Orofacial Pain, vol.
Hyperactivity of masticatory muscles resulting from parafunctional habits can lead to adaptive responses in dynamic balance because of hyperactivity and high load in the long term.
Excessive changes in any of the above functions can lead to disability to adapt leading to TMJ disorders. For example, external trauma to any part results in injuries and disorders in normal joint function.
The other cause of ankylosis is surgery that often results in fibrotic changes and reduced mandibular movements. The lateral pterygoid muscle, a heterogeneous unit implicated in temporomandibular disorder: a literature review. Moreover, anatomic, systemic, pathophysiological and emotional causes can make the disorder more severe. Clinical features: Patients have history of damage or capsulitis with reduced mandibular movements (which is painless). In fact, excessive trauma because of parafunctional forces can damage the masticatory system.
Retrodiscitis: Inflammation and degeneration is possible following excessive forces on retrodiscal tissues replete with nerves and vessels. These damages may result in joint injuries and pain in eating, smiling, yawing or excessive opening of the mouth. External trauma such as a punch, sport activities and injuries because of dental practice can lead to TMD.
Bilateral ankylosis in children results in severe retrognathia and bird face with open bite. Sudden trauma to the chin results in condyle pressure on retrodiscal tissues and thus, inflammation and degeneration may occur in the long-term.Diagnostic criteriaLocal concentrated pain at rest which becomes severe in function and clenching There is limitation in mandibular movement because of pain.
Maroldi, “TMJ disorders and pain: assessment by contrast-enhanced MRI,” European Journal of Radiology, vol. Postural habits such as head forwarding or holding the phone handset place pressure on joints and muscles which result in musculoskeletal pains such as headaches in TMD patients.
Additional habits and movements such as clenching, bruxism, attrition, lip biting and abnormal posture of the jaws common in society may lead to TMD.
This may follow long-term forces (for example clenching during sleep), hemarthrosis, macro trauma and or surgery. Although in some patients, it is known as an initial factor, parafunctional habits can be aggravated by stress, anxiety, sleeping and eating disorder.
Clinical features:In adhesion between disc and fossa, normal translational movement is limited, so the condyle just has rotational movement.
Morphometric analysis of the insertion of the upper head of the lateral pterygoid muscle. As we know, functional forces entering joint surfaces result in remodeling stimulation to adaptation of the condyle during life. In this case, opening range is about 25 to 30 mm.If this kind of adhesion occurs permanently in the superior joint space, the disc remains posterior to the condyle which in fact is posterior dislocation of the disc.
Anatomical factorsAnatomical factors affecting the TMJ can be hereditary, developmental or acquired. However, if forces are more than adaptive capacity and condyle remodeling, degeneration or osteoarthritis will appear. In milder forces to joint surfaces and bone remodeling with no symptoms, it is named osteoarthrosis as conditions are stable but the shape of bone changes.Clinical observationsIt is painless. However, millimetric changes in face vertical dimension, overbite, over jet or cross bite alone, are not the only cause of TMD.
Limitation in mandibular movements and deviation to the affected side occurs on opening.Radiographic findingsBone remodeling, changes in shape and size which are signs of physiologic adaptive mechanical stress are seen.
In most patients with TMD, the muscles are tender to palpation and 40% of them have pain chewing food. Fibromyalgia is a chronic muscle pain.Myofacial painMyofacial pain can be misleading by tension type headache resulting from tiredness. Pathophysiological factorsThese include: degenerative disorders, endocrine disorders, infections and blood disorders. The chief compliant of the patient is various pains, recurrent pains, temporal headache etc.
Mental factorsStress and mental stresses, can result in excessive load on masticatory system and parafunctional habits. Osteoarthritis is a degenerative process of condyle and fossa surfaces resulting in their changes. So, it is highly important to consider the socio-mental factors upon examination of patients with TMD.
Osteoarthritis may be a component of a systemic disorder.EtiologyWhen articular surfaces are unable to bear the forces, the capacity of functional adaptation cannot respond and thus, degeneration ensues. Moss, “MR evidence of temporomandibular joint fluid and condyle marrow alterations: occurrence in asymptomatic volunteers and symptomatic patients,” International Journal of Oral and Maxillofacial Surgery, vol.
If bony changes are active, it is named osteoarthritis.Clinical featuresLimitation of opening is present because of articular pain.
Prevalence of the third head of the lateral pterygoid muscle a magnetic resonance image study.
As there are numerous similar disorders and pains in the head and neck region, differential diagnosis is paramount (Table 1).1. A possible etiology of the internal derangement of the temporomandibular joint based on the MRI observations of the lateral pterygoid muscle. Increased T2 signal in the retrodiskal tissue of painful joints,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and endodontics, vol. Emshoff, “Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging,” Journal of the American Dental Association, vol. Guidelines for Assessment, Diagnosis, and Management, Quintessence, Chicago, Ill, USA, 1996. A macroscopic and microscopic study of the relationship between the superior lateral pterygoid muscle and the disk of the temporomandibular joint. Gernet, “Variability of disk position in asymptomatic volunteers and patients with internal derangements of the TMJ,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, vol.
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II: reliability of Axis I diagnoses and selected clinical measures,” Journal of Orofacial Pain, vol. V: methods used to establish and validate revised Axis I diagnostic algorithms,” Journal of orofacial pain, vol. Palla, “Individualized oblique-axial magnetic resonance imaging for improved visualization of mediolateral TMJ disc displacement,” Journal of Orofacial Pain, vol.
Guidelines for Classification, Assessment, and Management, Quintessence, Chicago, Ill, USA, 1993. Arici, “Effects of fixed functional appliance treatment on the temporomandibular joint,” American Journal of Orthodontics and Dentofacial Orthopedics, vol. Townsend, “A prospective study of Twin-block appliance therapy assessed by magnetic resonance imaging,” American Journal of Orthodontics and Dentofacial Orthopedics, vol.
Meyer, “A cephalometric and tomographic evaluation of Herbst treatment in the mixed dentition,” American Journal of Orthodontics and Dentofacial Orthopedics, vol. Nanda, “Prospective study of posttreatment changes in the temporomandibular joint,” American Journal of Orthodontics and Dentofacial Orthopedics, vol. Sharma, “Temporomandibular joint adaptations following two-phase therapy: an MRI study,” Orthodontics and Craniofacial Research, vol.
Brooks, “Temporomandibular joint: Relationship between MR evidence of effusion and the presence of pain and disk displacement,” American Journal of Roentgenology, vol. Iizuka, “Correlation between pain and synovitis in patients with internal derangement of the temporomandibular joint,” Journal of Oral and Maxillofacial Surgery, vol.
Bazan, “Identification of prostaglandin E2 and leukotriene B4 in the synovial fluid of painful, dysfunctional temporomandibular joints,” Journal of Oral and Maxillofacial Surgery, vol. Murata et al., “Magnetic resonance imaging of sonovial proliferation in TMJ disorders and pain,” Journal of Computer Assisted Tomography, vol. Naeije, “Mandibular movement characteristics of an anterior disc displacement with reduction,” Journal of Orofacial Pain, vol. Naeije, “Two-year natural course of anterior disc displacement with reduction,” Journal of Orofacial Pain, vol.



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