TMJ disc displacements
Original Editor - Andrea Reineke
Temperomandibular joint displacement also known as internal disc derangement is an abnormal relationship between the articular disc and the mandibular condyle and the mandibular fossa. 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.
Stages of TMJ disc displacement:
Stage I: Disc displacement with reduction DDWR (hearing and palpating joint noises during opening and closing, protrusive opening and closings stops the reciprocal click)
Stage II: Disc displacement without reduction DDWoR (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)
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
- Pain or discomfort associated with anyone or combination of: chewing, yawning, talking, bruxism,
- Mouth opening may or may not be limited
- Joint noises during jaw movement (clicking or crepitus)
- Pain or discomfort can be acute or chronic that can fluctuate in intensity.
Duration of symptoms may vary from hours to days. Symptoms may include anyone or combination: jaw/facial pain, headaches, ear pain
- Neurological signs (numbness)
- Swelling and or lymphadenopathy
- Nosebleed or stuffiness or drainage, and dysphagia
- Unexplained weight loss
- Auditory complaints
- Constant pain unrelated to jaw movement
- Unchanging symptoms in spite of different treatment.
- Clearing the TMJ could be done with the following imaging: Radiography (normal x-ray and panoramic radiography), Tomogram, Computerized tomography (CT scan), MRI, Arthrography.
- 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
- 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
Treatment for disc displacement with reduction (DDwR) without pain: requires no treatment other than:
- Explain to the patient what it is they are experiencing that popping may continue indefinitely, they may experience occasional brief moments of locking.
- Reassure the patient that 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:
- Inform patient that their head, orofacial and neck symptoms may not be related to the DDwR.
- 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)
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):
- Reposition the disc into the condyle
- Decrease frequency and duration of locking episodes
- Progress DDwR to a functional non-reducing disc.
- 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
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