TMJ disorders / fellowships in orthodontics
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TMJ DisordersTMJ DisordersINDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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ContentsContents IntroductionIntroduction EpidemiologyEpidemiology EtiologyEtiology ClassificationClassification Clinical featuresClinical features Radiological features Radiological features Histopathologic featuresHistopathologic features TreatmentTreatment
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IntroductionIntroduction
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EpidemiologyEpidemiology
Epidemiologic studies Epidemiologic studies 60-70% 60-70%
20-40 years. 20-40 years.
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EtiologyEtiology Multifactorial:Multifactorial:
Parafunctional habitsParafunctional habits StressStress TraumaTrauma
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Abnormal maxillo-mandibular relationships. Abnormal maxillo-mandibular relationships.
Rheumatic / musculo-skeletal disorders. Rheumatic / musculo-skeletal disorders.
Poor general health and unhealthy lifestyle. Poor general health and unhealthy lifestyle.
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AnatomyAnatomy
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Normal histology of TMJNormal histology of TMJ
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ClassificationClassification(Etiology)(Etiology)
I. I. Developmental Developmental
AplasiaAplasia
HypoplasiaHypoplasia
HyperplasiaHyperplasia
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II. II. TraumaticTraumatic
AnkylosisAnkylosis
Injuries of the articular disk Injuries of the articular disk
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III. Fractures of the condyleIII. Fractures of the condyle
IV. IV. Inflammatory Inflammatory
ArthritisArthritis
Rheumotoid arthritisRheumotoid arthritis
OsteoarthritisOsteoarthritis
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V. V. NeoplasticNeoplastic
VI. VI. Extra-articular disturbancesExtra-articular disturbances
VII. Temporomandibular jointVII. Temporomandibular joint syndrome syndrome
(TMD)(TMD)
TMD secondary to myofacial pain and TMD secondary to myofacial pain and
dysfunction (MPD)dysfunction (MPD)
TMD secondary to true articular disease.TMD secondary to true articular disease.www.indiandentalacademy.com
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DEVELOPMENTAL DEVELOPMENTAL DISTURBANCESDISTURBANCES
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Aplasia of the mandibular condyleAplasia of the mandibular condyle Unilateral / bilateral. Unilateral / bilateral. Rare Rare
C/FC/F Associated-- absent external Associated-- absent external ear ear ,under ,under
developed ramus / macrostomia. developed ramus / macrostomia. Facial asymmetryFacial asymmetry
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TreatmentTreatment
OsteoplastyOsteoplasty
Orthodontic appliancesOrthodontic appliances
Cosmetic surgeryCosmetic surgery
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Hypoplasia of the mandibular Hypoplasia of the mandibular
condylecondyle:: Under development / defective Under development / defective
formation formation
Congenital hypoplasiaCongenital hypoplasia Idiopathic Idiopathic Characterized by uni / bilateral under Characterized by uni / bilateral under
development of the condyledevelopment of the condylewww.indiandentalacademy.com
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Acquired hypoplasiaAcquired hypoplasia
Forceps deliveries Forceps deliveries
External traumaExternal trauma
X-ray radiationX-ray radiation
InfectionInfection
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C/f:C/f: Depends Depends
Degree of malformation. Degree of malformation.
AgeAge
DDurationuration
UnilateralUnilateral
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Limited lateral movementsLimited lateral movements
Midline shift Midline shift
Lack of downward and forward Lack of downward and forward
growth of the mandible growth of the mandible
Arrest of the Arrest of the chief growth centerchief growth center of of
the mandible i.e., the mandible i.e., condyle.condyle.
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Treatment & prognosis:Treatment & prognosis:Cartilage / bone transplantsCartilage / bone transplants
Unilateral and bilateral Unilateral and bilateral
osteotomyosteotomy
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Hyperplasia of the mandibular condyleHyperplasia of the mandibular condyle::
Rare Rare unilateral enlargement of the condyle unilateral enlargement of the condyle Causes: Causes:
-Obscure -Obscure
-Mild chronic inflammation.-Mild chronic inflammation.
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C/f: C/f:
Elongation of the face Elongation of the face
deviation of the chin away from the deviation of the chin away from the
affected side. affected side.
Enlarged condyleEnlarged condyle
may or may not be painfulmay or may not be painful
severe malocclusionsevere malocclusionwww.indiandentalacademy.com
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R/F:R/F: Elongated neck and enlarged Elongated neck and enlarged
condylar head condylar head
Treatment and prognosis:Treatment and prognosis: Condylectomy Condylectomy Orthognathic surgery Orthognathic surgery Resection of condyleResection of condyle
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Condylar hyperplasia
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Bifid condyleBifid condyle Double headed.Double headed. Medial & lateral head. Medial & lateral head. //Anterior & Anterior &
posterior head.posterior head.
Etiology:Etiology: Uncertain.Uncertain. Traumatic in origin.Traumatic in origin. Abnormal muscle attachmentAbnormal muscle attachment
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C/F:C/F: UnilateralUnilateral AsymptomaticAsymptomatic Pop or click of TMJ Pop or click of TMJ
R/F:R/F: Bilobed appearance Bilobed appearance
Asymptomatic Asymptomatic no no treatment necessary.treatment necessary.
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Histologic section of bifid Histologic section of bifid condylecondyle
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TraumaticTraumatic
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Luxation and subluxationLuxation and subluxation
Dislocation of the TMJ Dislocation of the TMJ Luxation of the joint Luxation of the joint
SubluxationSubluxation
Luxation Luxation ‘acute’, due to a sudden ‘acute’, due to a sudden
traumatic injury resulting in the fracture of traumatic injury resulting in the fracture of
the condyle. the condyle.
Yawning / wide opening of mouthYawning / wide opening of mouthwww.indiandentalacademy.com
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Unilateral condylar dislocationwww.indiandentalacademy.com
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Bilateral condylar dislocationwww.indiandentalacademy.com
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Luxation & SubluxationLuxation & Subluxation C/f:C/f:
Sudden locking and immobilization of the Sudden locking and immobilization of the
jaws. jaws.
Prolonged spasmodic contraction of the Prolonged spasmodic contraction of the
temporal, internal pterygoid and masseter temporal, internal pterygoid and masseter
muscles. muscles.
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Luxation & SubluxationLuxation & Subluxation
Treatment:Treatment: Relaxation of the muscles and then guiding the Relaxation of the muscles and then guiding the
head of the condyle under the articular eminence head of the condyle under the articular eminence into its normal position by an inferior and posterior into its normal position by an inferior and posterior pressure of the thumbs in the mandibular molar pressure of the thumbs in the mandibular molar area.area.
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AnkylosisAnkylosis Fusion of head of the condyle Fusion of head of the condyle temporal temporal
bone.bone.
EtiologyEtiology:: Idiopathic Idiopathic
Traumatic injuriesTraumatic injuries
InfectionInfection
Rheumatoid arthritisRheumatoid arthritiswww.indiandentalacademy.com
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AnkylosisAnkylosis C/f:C/f:
11stst decade decade Before 10 yearsBefore 10 years M = FM = F Unilateral /BilateralUnilateral /Bilateral In ability to open the jawsIn ability to open the jaws Pain, tenderness and malocclusion Pain, tenderness and malocclusion
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Unilateral ankylosis
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AnkylosisAnkylosisIntra-articular Intra-articular ankylosisankylosis
Extra-articular Extra-articular ankylosisankylosis
-Destruction of the -Destruction of the
meniscusmeniscus
-Flattening of the -Flattening of the
mandibular fossa mandibular fossa
thickening of the head thickening of the head
of the condyle of the condyle
-narrowing of the joint -narrowing of the joint
spacespace
-Fibrous adhesion-Fibrous adhesion
External fibrous / External fibrous /
osseous encapsulation.osseous encapsulation.
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AnkylosisAnkylosis R/F:R/F:
Abnormal / irregular shape of the Abnormal / irregular shape of the head of the condylehead of the condyle
Treatment:Treatment: Surgical osteotomy / removal of Surgical osteotomy / removal of
section of bone below the condyle.section of bone below the condyle. Fibrous ankylosis can be treated by Fibrous ankylosis can be treated by
functional methods. functional methods. www.indiandentalacademy.com
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Injuries of the articular Injuries of the articular diskdisk
MalocclusionMalocclusion Loss of adaptation of the disk to Loss of adaptation of the disk to
the condyle.the condyle.
Precipitating factorsPrecipitating factors Blow / fallBlow / fall Rheumatoid arthritisRheumatoid arthritis
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C/f:C/f: FemalesFemales
Young adults Young adults frequently affected. frequently affected.
Pain, snapping or clicking and Pain, snapping or clicking and
crepitation. crepitation.
Transient / prolonged locking of the Transient / prolonged locking of the
jaw may occur. jaw may occur. www.indiandentalacademy.com
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Injuries of the articular Injuries of the articular diskdisk
Normal disc position Normal disc position Anterior disc Anterior disc displacement displacement
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Injuries of the articular Injuries of the articular diskdisk
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Injuries of the articular Injuries of the articular diskdisk
R/F:R/F:No +ve findingsNo +ve findings
Treatment:Treatment: Immobilization Immobilization Menisectomy / surgical Menisectomy / surgical
removal of the disk.removal of the disk.www.indiandentalacademy.com
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Fractures Fractures
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Condylar fracture:Condylar fracture:
Traumatic injuryTraumatic injury
Limitation of motionLimitation of motion
Pain and swellingPain and swelling
Displaced anteriorly and medially into Displaced anteriorly and medially into
the infratemporal regionthe infratemporal regionSurgical reduction
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Unilateral
Bilateral www.indiandentalacademy.com
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INFLAMMATORY INFLAMMATORY DISTURBANCES DISTURBANCES
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Arthritis.Arthritis.3 types :3 types :
1.1. Arthritis due to a specific infection.Arthritis due to a specific infection.
2.2. Rheumatoid arthritis.Rheumatoid arthritis.
3.3. Osteoarthritis / degenerative joint Osteoarthritis / degenerative joint
disease.disease.www.indiandentalacademy.com
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UncommonUncommonNeisseria gonorrhea, Str, Staph. Neisseria gonorrhea, Str, Staph. Pneumococci, tubercle bacilli, H. Pneumococci, tubercle bacilli, H. influenzaeinfluenzae
Direct spread of a local infection or blood Direct spread of a local infection or blood stream / lymphatic metastasis.stream / lymphatic metastasis.
C/F:C/F:- - Severe pain in the joint.Severe pain in the joint. Extreme tendernessExtreme tenderness Healing Healing results in ankylosis. results in ankylosis.
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H-PH-P Destruction Destruction articular cartilage and articular cartilage and
articular disc.articular disc. Obliteration of joint space Obliteration of joint space by the by the
development of granulation tissuedevelopment of granulation tissue Transforms into scar tissue.Transforms into scar tissue.
Rx:Rx: Antibiotics – in the acute phase Antibiotics – in the acute phase
Meniscetomy / condylectomy is advocated in Meniscetomy / condylectomy is advocated in the advanced cases.the advanced cases.www.indiandentalacademy.com
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Rheumatoid arthritisRheumatoid arthritis Chronic autoimmune disorder Chronic autoimmune disorder non-suppurative inflammatory non-suppurative inflammatory
destruction of the joints.destruction of the joints. Etiology: Etiology:
UnknownUnknown Cross reaction of antibody against Cross reaction of antibody against
microorganisms deposited in the synovial microorganisms deposited in the synovial
membrane.membrane. www.indiandentalacademy.com
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A reactive macrophage – laden A reactive macrophage – laden fibroblastic proliferation from the fibroblastic proliferation from the synovium creeps onto the joint synovium creeps onto the joint surface.surface.
↓↓
Releases collagenases & proteasesReleases collagenases & proteases
↓↓
Destroys the cartilage & boneDestroys the cartilage & bone TMJ involvement TMJ involvement 20%20%
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C/F:C/F:
M:F = 1:3M:F = 1:3
M = 25-30 yrs;M = 25-30 yrs; F = 35-45 yrs F = 35-45 yrs
Early stages manifestsEarly stages manifests
Rheumatoid arthritisRheumatoid arthritis
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Pain, swelling and stiffness joint Pain, swelling and stiffness joint
Clenching the teeth on one side Clenching the teeth on one side
produces pain of contra lateral joint. produces pain of contra lateral joint.
Destruction of condylar head Destruction of condylar head
receding chin & malocclusionreceding chin & malocclusion
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R/F:R/F:
Flattened condylar headFlattened condylar head
An irregular surface of temporal fossaAn irregular surface of temporal fossa
Anterior displacement of the condyleAnterior displacement of the condyle
High resolution CT High resolution CT erosions of the erosions of the
condyle & glenoid fossae.condyle & glenoid fossae.
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H-P :H-P :
Hyperplasia Hyperplasia of synovial lining cells of synovial lining cells
Hyperemia, edema Hyperemia, edema and inflammation of the and inflammation of the
synovial tissues synovial tissues
diffuse infiltration of chronic inflammatory diffuse infiltration of chronic inflammatory
cells into the articular architecture.cells into the articular architecture.
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destruction destruction of articular surface of the condyle.of articular surface of the condyle.
Invasion of the cartilage and its replacement by Invasion of the cartilage and its replacement by
granulation tissue. granulation tissue.
Perforation of meniscusPerforation of meniscus
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Lab findings:Lab findings: 80% of patients 80% of patients ↑rheumatoid ↑rheumatoid
factorfactorANA detected in ANA detected in
50%50%↑↑ESRESRMild anemia Mild anemia
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Rx & Prognosis:Rx & Prognosis:
Anti-inflammatory drugsAnti-inflammatory drugs
Corticosteoids.Corticosteoids.
Surgical interventionSurgical intervention
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OsteoarthritisOsteoarthritis
Disorder of articular cartilage, Disorder of articular cartilage, subcondral bone with secondary subcondral bone with secondary inflammation of the synovial membraneinflammation of the synovial membrane
Etiology:Etiology: unknown. unknown. GeneticGenetic Aging process.Aging process. Chronic microtrauma Chronic microtrauma Primary Primary above 50 yrs & asymptomatic above 50 yrs & asymptomatic Secondary Secondary due to trauma, metabolic due to trauma, metabolic
diseasediseasewww.indiandentalacademy.com
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C/F: C/F: Unilateral pain over the condyle & Unilateral pain over the condyle &
over muscles of masticationover muscles of mastication Limitation of mandibular opening Limitation of mandibular opening Crepitus and stiffness Crepitus and stiffness Deviation of mandible towards painful Deviation of mandible towards painful
sideside
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R / F:R / F: Obliteration of the joint spaceObliteration of the joint space Surface irregularities and Surface irregularities and
protruberancesprotruberances Flattening of the articular surface.Flattening of the articular surface. Radiolucent subchondral cystsRadiolucent subchondral cysts Ossification within the synovial Ossification within the synovial
membranemembranewww.indiandentalacademy.com
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H-P /F:H-P /F:
Degeneration of cartilage cellsDegeneration of cartilage cells
infiltration of chronic inflammatory cellsinfiltration of chronic inflammatory cells
Loss of osteocytes Loss of osteocytes
fatty degeneration & necrosis of the marrowfatty degeneration & necrosis of the marrow
Large degenerative space beneath the Large degenerative space beneath the
articular cartilage (Subchondral cysts)articular cartilage (Subchondral cysts)
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Rx:Rx: NSAIDs, heat, soft diet, rest and NSAIDs, heat, soft diet, rest and
occlusal splintsocclusal splints ArthroplastyArthroplasty Orofacial physiotherapy.Orofacial physiotherapy.
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NEOPLASTIC NEOPLASTIC
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Neoplasms and tumor-like growths, benign Neoplasms and tumor-like growths, benign
and malignant, may involve the TMJ. and malignant, may involve the TMJ. Etiology: Etiology: UnknownUnknown From embryonic mesenchymal remnants From embryonic mesenchymal remnants
of synovium.of synovium. That become metaplastic, calcify, break off That become metaplastic, calcify, break off
into the joint spaceinto the joint space Chondromas, osteomas and Chondromas, osteomas and
osteochondromas are common benign osteochondromas are common benign tumors. tumors.
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Osteochondroma – bone capped with Osteochondroma – bone capped with cartilage and dense collagenous tissuecartilage and dense collagenous tissuewww.indiandentalacademy.com
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CT scan and arthroscopy is CT scan and arthroscopy is necessary for accurate diagnosis.necessary for accurate diagnosis.
Rx:Rx: Conservative and surgical removal Conservative and surgical removal
of involved synovium and articular of involved synovium and articular disk.disk.
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EXTRA-EXTRA-ARTICULARARTICULAR
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A variety of extraarticular disturbances A variety of extraarticular disturbances may manifest themselves clinically as TMJ may manifest themselves clinically as TMJ problems.problems. Impacted molar teethImpacted molar teeth Sinusitis & Middle ear diseaseSinusitis & Middle ear disease Infratemporal cellulitisInfratemporal cellulitis Neuritis of the 3Neuritis of the 3rdrd division of the trigeminal division of the trigeminal
nerve.nerve. Odontolgia.Odontolgia. Overclosure of the mandible due to severe Overclosure of the mandible due to severe
dental attrition.dental attrition. Costen’s syndrome.Costen’s syndrome.
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TEMPORO MANDIBULAR TEMPORO MANDIBULAR JOINTJOINT
SYNDROME SYNDROME
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Most common cause of facial pain Most common cause of facial pain
after toothache.after toothache.
TMD can be classified broadly as:TMD can be classified broadly as: TMD secondary to myofacial pain and TMD secondary to myofacial pain and
dysfunction (MPD).dysfunction (MPD).
TMD secondary to true articular diseaseTMD secondary to true articular disease
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Etiology: Etiology:
Tissue injuryTissue injury
Physical stress Physical stress Bruxism and day time Bruxism and day time
jaw clenching in a stressed and anxious jaw clenching in a stressed and anxious
person.person.
Psychological & behavioural abnormalitiesPsychological & behavioural abnormalities
Poor nutritional statusPoor nutritional status
Genetic predisposition Genetic predisposition www.indiandentalacademy.com
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DIGAMMATIC RERESENTATION OF ETIOLOGY OF MPDS
PSYCHOPHYSIOLOGIC THEORY OF MPDS(Modified by LASKIN in 1969)
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C /F:C /F: Constant diffuse unilateral painConstant diffuse unilateral pain Severe in the morning and worsens as Severe in the morning and worsens as
day progressesday progresses Radiates to cervical region, shoulders Radiates to cervical region, shoulders
and backand back Limitation of jaw movement Limitation of jaw movement Deviation to the affected siteDeviation to the affected site
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VII. TEMPOROMANDIBULAR JOINT VII. TEMPOROMANDIBULAR JOINT SYNDROME (TM disorder)SYNDROME (TM disorder)
Cl / Ft:Cl / Ft:
Tenderness in MMTenderness in MM
Angle of mandibleAngle of mandible
Anterior temporal region & coronoid Anterior temporal region & coronoid
aspectaspectwww.indiandentalacademy.com
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Rx:Rx:
Physiotherapy Physiotherapy moist heat, TENS, moist heat, TENS,
Aucpressure, Acupuncture.Aucpressure, Acupuncture.
Behavioural and relaxation techniquesBehavioural and relaxation techniques
Occlusal splint therapyOcclusal splint therapy
NSAIDs, Muscle relaxants NSAIDs, Muscle relaxants www.indiandentalacademy.com
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2. True intra-articular disease :2. True intra-articular disease : Disk displacement disorder.Disk displacement disorder.
Chronic recurrent dislocations.Chronic recurrent dislocations. Degenerative joint disorders.Degenerative joint disorders.
Ankylosis.Ankylosis. InfectionInfection
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Etiology:Etiology: Malocclusion.Malocclusion. Jaw clenching.Jaw clenching. Bruxism.Bruxism. Personality disordersPersonality disorders Increased pain sensitivity.Increased pain sensitivity. Stress and anxiety.Stress and anxiety.
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C/F:C/F: Affects young woman aged 20-40 yrs.Affects young woman aged 20-40 yrs.
M:F – 1:4.M:F – 1:4.
In TMD pain is unilateral associated with In TMD pain is unilateral associated with
clicking, popping and snapping sounds.clicking, popping and snapping sounds.
Limited jaw opening due to pain / disk Limited jaw opening due to pain / disk
displacement.displacement.
Associated with chewing and may radiate to Associated with chewing and may radiate to
head.head.www.indiandentalacademy.com
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Treatment & Prognosis:Treatment & Prognosis:1. Self limiting.1. Self limiting.2. Conservative treatment involving 2. Conservative treatment involving
self care practices.self care practices. Rehabilitation aimed at Rehabilitation aimed at
eliminating muscle spasms.eliminating muscle spasms.3. NSAIDs 3. NSAIDs Prognosis is good.Prognosis is good.
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Investigations Investigations TMJTMJ TMJ imaging TMJ imaging
Panoramic radiographsPanoramic radiographs Transcranial viewTranscranial view Transpharyngeal viewTranspharyngeal view Transorbital viewTransorbital view Reverse Towne’s viewReverse Towne’s view Submento-vertex (SMV) viewSubmento-vertex (SMV) view Conventional tomographyConventional tomography ArthrographyArthrographywww.indiandentalacademy.com
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Computed tomography (CT)Computed tomography (CT)
Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)
ArthroscopyArthroscopy
Bone scanBone scan
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ReferencesReferences Shafer’s Textbook of Oral Pathology. 5Shafer’s Textbook of Oral Pathology. 5thth edition. edition. Neville: Oral & Maxillofacial Pathology. 2Neville: Oral & Maxillofacial Pathology. 2ndnd edition. edition. Jaffery P. Okeson – Management of Jaffery P. Okeson – Management of
Temporomandibular disorders and occlusion.Temporomandibular disorders and occlusion. Martin S. Greenberg, Michael Glick – Burkit’s oral Martin S. Greenberg, Michael Glick – Burkit’s oral
medicine and diagnosis.medicine and diagnosis. Franklin C.D.: Pathology of the temporomandibular Franklin C.D.: Pathology of the temporomandibular
joint. Current Diagnostic Pathology (2006): 12, 31-39.joint. Current Diagnostic Pathology (2006): 12, 31-39.
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