TMJ disc displacements

Original Editor - Andrea Reineke

Top Contributors - Andrea Reineke and George Prudden  

Clinically Relevant Anatomy

Muscles: lateral and medial pterygoids, temporalis, massater, diagastric, hyoids

Ligaments: Temporomandibular (lateral) ligament, Sphenomandibular ligament and Stylomandibular ligament

Articular disc/capsule: Anterior, Intermediate, and Posterior bands

Osteology: Mandible, Temporal bone

Innervations: Masseteric nerve, deep temporal nerve, auriculotemporal nerve[1]

Mechanism of injury/pathological process

An abnormal relationship between the articular disc and the mandibular condyle. The general consensus is that the posterior band of the disc generally lies in front of the condyle and that the condyle functions on the posterior attachment. Imaging studies have demonstrated that disc displacements are relatively common.[2]

Three stages of disc displacement[3]:
Stage I: Disc displacement with reduction (hearing and palpating joint noises during opening and closing, protrusive opening and closings stops the reciprocal click)
Stage II: Disc displacement without reduction (history of clicking and popping with or without intermittent locking, complaint of limited mouth opening)
Stage III: Chronic disc displacement without reduction (hearing multiple noises during opening and closing (crepitus), with normal or near normal mandibular dynamics[4])

Clinical presentation

History: 1) Pain or discomfort associated with anyone or combination of: chewing, yawning, talking, bruxism, 2) Mouth opening may or may not be limited, 3) Joint noises during jaw movement (clicking or crepitus), 4) Pain or discomfort can be acute or chronic that can fluxuate in intensity. Duration of symptoms may vary from hours to days. Symptoms may include anyone or combination: jaw/facial pain, headaches, ear pain[5]

Red flags: 1) neurological signs (numbness), 2) swelling and or lymphadenopathy, 3) nosebleed or stuffiness or drainage, and dysphagia, 4) unexplained weight loss, 5) auditory complaints, 6) constant pain unrelated to jaw movement, 7) unchanging symptoms in spite of different treatment.

Diagnostic Procedures

Clearing the TMJ could be done with the following imaging: Radiography (normal x-ray and panoramic radiography), Tomogram, Computerized tomography (CT scan), MRI, Arthrography.[6][7][8][9][10]

Measurements of maximal mouth opening using a standard ruler have demonstrated an intra- rater reliability of .99 (ICC) and an inter- rater reliability of .94[11]

Auscultation During Active Movement- to identify presence of OA on the TMJ. Positive test if crepitus heard by examiner. Sn= .45-.67, Sp= .84-.86, -LR=.38-.65, +LR= 2.8-4.8[12]

Management/Intervention

Treatment for disc displacement with reduction (DDwR) without pain: requires no treatment other than- 1) Explain what it is they are experiencing that popping may continue indefinitely, they may experience occasional brief moments of locking. 2) Reassure what they have is very common, their condition rarely deteriorates to the level of having chronic pain and loss of oral function.

Treatment for DDwR with pain: 1) Inform patient that their head, orofacial and neck symptoms may not be related to the DDwR. 2) Treat other sources of symptoms that may be unrelated to the DDwR such as: joint inflammation (physical therapy/anti-inflammatory meds), masticatory muscle pain (physical therapy/oral appliance), and referred pain from cervical spine (physical therapy)[13]

Treatment of DDwR with locking episodes (patient experiences sudden episodes of limited mouth opening, which returns to normal with spontaneous resolution or resolution in response to force exerted by the patient): 1) Reposition the disc into the condyle, 2) Decrease frequency and duration of locking episodes, 3) Progress DDwR to a functional non-reducing disc.[14]

Since cervical spine disorders coexist 70% of the time with TMD it is very important to screen and treat the cervical spine as necessary[15][16][17]

Differential Diagnosis

TMJ differential diagnoses:
Pseudo-hypomobilities: muscle spasm, acute surgical, intra and extracapsular irritations, neoplasm, inflammatory diseases, and trauma
True hypomobilities: chronic post-surgical, arthritic, fibrosis adhesions

Recent Related Research (from Pubmed)

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References

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  1. Thilander B. Innervation of the temporomandibular disc in man. Act Odontol Scan. 1964: 22:151.
  2. Kircos L., Ortendahl D., Mark A. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. Journal of Oral and Maxillofacial Surgery. 1987: 45;852.
  3. Moffett BC. Definitions of TMJ Derangements. IN: Diagnosis of internal derangements of the TMJ, Vol.1, Double contrast Arthrography and Clinical considerations. BC Moffett and PL Westesson eds. Proceedings of a Continuing Dental Symposium, Seattle 1984.
  4. Eriksson L and Westesson PL. Clinical and radiological study of patients with Anterior disc displacement of the temporomandibular joint. Swed Dent J. 1983; 7:55.
  5. Dworkin SF, Turner JA, Manci L, et al. A Randomized Clinical Trial of a Tailored Comprehensive Care Treatment Program for Temporomandibular Disorders. J Orofac Pain. 2002;16:4.
  6. Kraus S. (1994). Clinics in Physical Therapy: Temporomandibular Disorders (2nd edition). Churchill Livingstone: New York.
  7. Helms CA, Kaplan R. Diagnostic imaging of the temporomandibular joint: recommendations for use of the various techniques. AM J Roentgenol. 1990: 154;319.
  8. Pharoah M. The prescription of diagnostic images for temporomandibular joint disorders. J of Orofascial Pain. 1999; 13(4): 251-254.
  9. Trumpy I, Erickson J, Lyberg T. Internal derangement of the temporomandibular joint: Correlation of arthrographic imaging with surgical findings. Int J Oral Maxillofac Surg. 1997; 26:327-330.
  10. Watt-Smith S, Sadler A, Baddeley H, et al. Comparison of arthrotomographic and magnetic resonance images of 50 temporomandibular joints with operative finds. Br J Oral Maxillofac Surg. 1993; 31:139-143.
  11. Walker N, Bohannon RW, Cameron D. Discriminant validity of temporomandibular joint range of motion measurements obtained with a ruler. J Orthop Sports Phys Ther. 2000 August;30(8): 484-92.
  12. Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for an Evidence-based Clinician. EIM. 2008:180.
  13. Moses JJ, Topper DC. A functional approach to the treatment of temporomandibular joint internal derangement. J Craniomandib Disor Facial & Oral Pain. 1991; 519-27.
  14. Yoda T, Sakamoto I, Imai H, et al. Response of temporomandibular joint intermittent closed lock to different treatment modalities: A multicenter Survey. J Craniomadndib Practice. 2006; 24(2): 130-6.
  15. Ciancaglini R, Testa M, Radaelli G. Association of neck pain with symptoms of TMD in the general adult population. Scand J Rehab Med. 1999; 31:17-22.
  16. Sjaastad O, Saunte C, Hovdal H, et al. “Cervicogenic” headache. An hypothesis. Cephalalgia. 1983; 3:249-256.
  17. Kuttila S, Kuttila M, Le Bell Y, et al. Characteristics of subjects with secondary otalgia. Journal of Orofacial Pain. 2004; 18(3):226-234.