Pathology and Medical Management
TMJ
Disorders and Diseases
Symbols

this is for your information only,
it won’t be used for the exam
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important to know for exam
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Temporomandibular Joint Imaging
Radiography:
◦ Fractures which might
occur.
◦ Can also get an idea of
the joint position
 Generally not as useful
as other types of imaging
studies
 Standard Views:
◦ Transcranial View
◦ Submentovertex view
◦ Cephalometry: lateral
views


MRI: T1-weighted
sagittal images are the
method of choice for
TMJ examination.
◦ Articular disk position

T2 weighted images
◦ Periarticular changes
◦ Joint effusions

CT
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Figure 5. a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed
position.
Sommer O J et al. Radiographics 2003;23:e14-e14
©2003 by Radiological Society of North America
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TMJ Dysfunctions
Non Articular
Articular
Non-Inflammatory
Inflammatory
Articular Disk
Displacement
MPDS
Synovitis and
Capsulitis
With Reduction
Myositis
Spasm
Arthritic Disorders
Without
Reduction
Osteoarthritis
Muscle
Contracture
Deviation in Form
Rheumatoid
Arthritis
Dislocation and
Subluxation
Other
Ankylosis
Bony
Fibrosis
www.geocities.com/dentalsem/Temporomandibular...
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Articular Disk
Displacements with Reduction

Partial Anteromedial Disk Displacement
◦ Disk slides anterior on the condyle
◦ Posterior band is more anteriorly placed than
normal
◦ Etiology:
 Thinning of the posterior band
 Minimal elongation of diskal ligaments
◦ TX: intro-oral appliances in combination with
stress reduction
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Disk Displacement

Anteromedial Disk Displacement with
Reduction
◦ Definition: Change in the disk-condyle structural
relation during mandibular translation with mouth
opening and closing
◦ Etiology:





Articular surface irregularity
Disk-articular surface adherence
Synovial fluid degradation
Myofascial imbalances around the joint
Increased elongation of diskal ligaments and posterior
attachment
www.urmc.rochester.edu/smd/Rad/tmj.htm
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5 Progressive Stages

Stage I Disk Displacement
◦ Temporal mandibular ligament becomes
elongated
◦ Disk drops medially - subluxes which reduces
upon closure
◦ Ligament brings the disk back into place upon
closure
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Symptoms of Stage 1:

Very little pain

Inconsistent click occurs early in opening
phase.

Subluxation on opening and a lateral
reduction in closing
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Stage II Disk Displacement

TM ligament continues to elongate, disk
moves more medial and anterior on
mandibular head.
Reduction on mouth opening, subluxation
on closing
 Clicking: Early on opening and Late on
closing

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Figure 11. Partial anterior disk displacement.
Sommer O J et al. Radiographics 2003;23:e14-e14
©2003 by Radiological Society of North America
12

Symptoms of 2:
◦ Reciprocal click early on
opening and late on
closing
◦ Pain

Signs: C curve upon
mouth opening: goes
back and lateral
towards dysfunctional
side.
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Open Lock:


Potential to occur from Stage II on
Signs: two opening clicks
 Two closing clicks
 Condyle can be prevented from slipping back in
place if disk lies too posterior to the condyle
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Stage III
Significant TM ligament elongation
overstretching occurs causing posterior
ligament elongation, disk shape distorted.
 Condyle loses vertical height
 Capsule becomes shortened

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
Symptoms 3: click is more consistent
Click occurs later on opening and earlier on
closing
◦ Most painful stage
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Signs:
◦ C curve
◦ Limited range of mouth opening to 25 to 30 mm, just
below functional: 35mm is limit.
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Closed Lock condition

Closed lock: sudden limitation of jaw
opening
◦ Disk is permanently lodged anteriorly and
interferes with normal rotation and
translation of the joint
◦ Hard end-feel
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Stage IV: Rotational Displacement

Symptoms: Pain

Signs:
◦ Clicking rare or single opening click
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Stage V:
Signs: radiographic degenerative changes
on condylar head, articular eminences
(less often)
 Evidence of remodeling (sclerosis) and
osteophytes
 Marked deformity of disk, thickening of
disk and shape change

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C. Anteromedial Disk Displacement with
Intermittent Locking
Disk is displaced
 Shape is deformed over time from
biconcave to biconvex


Symptoms: intermittent locking in the am
or after a period of clenching or chewing
on involved side, brucsizum (teeth
clenching @ night)
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D. Anteromedial Disk Displacement without
Reduction

Definition: change of the disk-condyle
structural relationship which is maintained
during mandibular translation
◦ Disk remains displaced with a closed-lock occurring
◦ Lose: contact with condyle, disk and articular
eminence of condyle which prevents posterior
translation from occurring

Signs:
◦ Deviation of mandible towards involved side
◦ Marked limitation of lateral deviation to contralateral
side
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Internal Derangement
of the Disk

Deviation in Form
◦ Frictional Disk Incoordination:
 Definition: intra-articular disk adheres to the
eminence
 Onset:
 Etiology: loss of lubrication, roughness in the
articular surface
 Signs: loss of translatory glide
 opening click
 Symptoms: minimal discomfort with the click
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Deviation in Form

Articular Surface Defects
◦ Definition: articulating surface has a roughed area or
a change in the articular cartilage which doesn’t allow
smooth rolling or gliding during opening and closing
of the mouth
◦ Etiology:
◦ Signs: reciprocal click during opening and closing of
the mouth
 Lateral deviation on opening
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Deviation in Form

Disk Thinning and perforation
◦ Etiology: application of excessive pressure on
the TMJ, overloading with teeth together
◦ Symptoms: variable joint tenderness, muscle
pain
◦ Signs: grating sound, crepitus during opening
and closing
◦ DX: made with medical imaging studies
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Hypermobility and Dislocation
-Hyper: at risk for a locked open mouth.
 Subluxation


Dislocation

Hypomobility: capsular vs adhesive disk
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A. Joint Subluxation

Mandibular Head Subluxation
1. Biomechanical considerations
2. Arthrokinematic dysfunctions
a. max. rotation occurs before
translation begins
b. maximum translation occurs
and a shift of condyle and
disk as a unit occurs
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Subluxation versus Reduction of
Displaced Disk

Subluxed Disk:
◦ Occurs only on wide opening
◦ Does not occur with protrusion or lateral
deviation
◦ Pain is not always present

Reduction Disk:
◦ Occurs on opening for stage I, closing (except
in stage 1) and protrusion and contra-lateral
lateral deviation
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B. Joint Dislocation

Condyle moves outside of the physiological
boundaries of the joint

Etiology: yawning (to wide), singing, sleeping
with head on forearm, excessive tooth abrasion,
malocclusion, over-closure and trauma

Sx: open lock position mouth is unable to close,
locked open

Rx: manipulation, splint
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Ankylosis: stuck

Fusion of TM joint

◦ Fibrosis
Symptoms:
◦ Opposite side may
become painful
◦ Bony

Signs:
◦ Decreased ROM
◦ C curve on mouth
opening

Tx
◦ How to f(x) with it.
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Adhesive Disk Hypomobility

Definition: intra-articular formation of
adhesions within the disk
◦ Usually in the superior joint cavity, causes loss
of condylar translation
◦ Condylar displacement of disk may occur
◦ Distortion of disk on mouth opening
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Adhesive Hypomobile

Etiology:
◦ Trauma: mild may only cause frictional disk
incoordination or articular surface defect
◦ Major: intra-articular bleeding, swelling,
fibrosis can result
 Restricts ROM
 May progress to joint degeneration
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
Sx: Click –
◦
◦
◦
◦

Early is within 10 mm of opening,
Intermediate between 10 and 20 mm,
Late after 30 mm of opening.
C/o a locking sensation
Signs:
◦ mandible deviates away from the dysfunctional side
during mouth opening
◦ S-curve: jaw goes to both sides correcting and
over-correcting.
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Inflammatory Conditions

Synovitis and Capsulitis
◦ Retrodiscitis

Arthritic Conditions
◦ Osteoarthritis
◦ Rheumatoid Arthritis
◦ Other Arthritic Conditions
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Capsulitis
◦ SX: continuous deep constant pain
 Originates in joint area
 Pain with mouth opening
◦ Signs: palpable pain with compression to the lateral
pole of condyle
Limitation of mouth opening
Myospasms secondary to pain
Tissue stretch end feel or empty end feel
Decreased protrusion , may deviate to side of
dysfunction
 Increase pain with passive stretch




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Retrodiscitis

Anterior displacement
of disk, condyle presses
on posterior tissue
causing an inflammatory
reaction
Hx: trauma, chronic
bruxing
SX: constant, dull, aching
pain, aggravated by joint
movement
-closure puts it back into
place.
Signs: empty end feel, acute
malocclusion, decrease
protrusion, pain with
compression
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Non-Articular Conditions

Muscle Spasms
◦
◦
◦
◦
Masseter
Temporalis
Lateral Pterygoid
Medial Pterygoid
Myositis
 Myofascial Pain Syndrome
 Muscle Contracture

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Practice Pattern 4E:

Muscle Spasms
◦ Causes: trauma, occlusal imbalance, changes
in vertical dimensions between teeth,
immobilization, prolonged dental procedures,
chronic teeth clenching, disease
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Three Categories of Muscle Spasms
Protective Co-contraction: muscle
guarding
1.
◦
Causes: Chronic inflammatory process, emotional
stress, habit, muscle tendon injury

Sx: pain with active jaw movement

Signs: pain with resisted movements, pain at
end range with passive movements, empty end
feel or muscle spasm end feel
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2. Local Muscle Spasm

Protective muscle co-contraction,
◦ Leads to prolonged isometric contraction of muscle.
◦ Leads to decrease in blood flow,
◦ Inflammatory response, increase pain, increase muscle guarding,
more pain

History: blow to face, dislocation of jaw

SX: periarticular, pain with chewing

Signs: pain with AROM mouth opening, PROM, Resisted
muscle testing, dec. in mouth opening pain with
overpressure during mouth opening
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3. Specific Muscles, Trigger Points
1. Temporalis
a. HX: headaches in temporal region
b. SX: headaches, visual disturbances,
pressure behind eye, increase
eye fatigue, difficulty with night vision
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c. Signs:

◦ Muscle trigger point with
referred pain pattern

◦ S curve on mouth opening
◦ Decrease in freeway space
(mouth opening at rest)

◦ Abnormal protrusion of
condyle on contralateral
side during lateral deviation
◦ Intermittent tooth ache
Restriction of mouth
opening
Deviation of mouth
toward affected side
Pain with palpation
Pain with resisted
motions of elevation
but not protrusion
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2. Masseter
a. HX:
c. Signs:
b. SX:

pain to lower jaw, molar
teeth and related gums,

pain with chewing or with
increased jaw activity

unilateral tinnitus

Bruxism: jaw clenching
◦ restriction of mouth opening
◦ deviation of mouth toward
affected side
◦ pain with palpation
◦ referred pain pattern upon
compression
◦ pain with resisted motions of
elevation but not protrusion
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3. Medial Pterygoid
Ache inside the mouth
c. Signs:
◦ Restriction in mandibular opening
a. HX:
◦ No deviation of jaw
b. SX:
◦ Rarely the primary muscle, Usually
a 2ndary area
◦ Pain with wide mouth
opening
◦ pain with clenching
teeth
◦ painful swallowing
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4. Lateral Pterygoid:
“TMJ” dysfunction
a. SX:
◦ Pain in region of
TMJ and maxilla
◦ Clicking sounds
may occur, so
need to be careful
to d(x)
b. Signs:
◦ Pain with compression on
same side as dysfunction
◦ Slight restriction of mouth
opening, occlusal
abnormality
◦ ROM: for Lateral deviation
away from the side of
dysfunction is decreased
◦ ROM decreased
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Oncological
A. Rare occurrences, but can get a metastatic
adenocarcinoma in the TMJ region
B. Signs: unrelenting pain of unexplained origin,
neurological deficits, nausea,
balance disorders, visual changes, cranial nerve
disorders
C. Refer if suspect
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PT TREATMENT OF TMJ
DYSFUNCTIONS
Goals are based on physical exam
1. Treat pain:
2. Address biomechanical asymmetries
3. Postural education: like forward head
4. Strengthen supporting structures
necessary to balance head, maintain new
position
5. Stress reduction
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Occlusional appliance:

Splint: removable,
hard, acrylic “bite
guard”
a. muscle relaxation
b. anterior
(orthopedic)
repositioning
appliance
c. anterior bite plate
d. posterior bite
plate
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Medical Treatment:

Arthroscopic surgery done for disk
repositioning

Decrease adhesions

Take out osteophytes
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Other References:
1. Bourbon BM: “Craniomandibular
Examination and Treatment” in Saunders
Manual of Physical Therapy Practice, WB
Saunders Co. Philadelphia, 1995
2. Richardson JK and Iglarsh ZA. Clinical
Orthopaedic Physical Therapy, W.B. Saunders
Co., Philadelphia, 1994.
3. Magee D. Orthopedic Physical
Assessment, 4th ed. 2002
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