11/14/24, 10\:40 AM Temporomandibular Dysfunction (TMD)
Temporomandibular Dysfunction (TMD)
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Temporomandibular dysfunction (TMD)\: disorders causing pain in pre-auricular area and muscles of mastication; most
common non-dental cause of orofacial pain.
Anatomy\: TMJ connects skull to lower jaw; includes mandibular fossa, articular disc, mandibular condyle, supporting
ligaments; superior compartment for translational movement, inferior compartment for rotational movement.
Causes\: multifactorial; includes stress, low mood, bruxism (tooth grinding), co-morbidities (e.g.,
teeth/face causing malocclusion.
Symptoms\: pre-auricular pain radiating to jaw and temporal region, clicking sounds (crepitus), locking (articular disc
trapping), trismus (di
Clinical signs\: TMJ tenderness, masseter/temporalis tenderness, TMJ crepitus, trismus, jaw locking.
Examination\: inspect mouth for dental pathology and occlusion, palpate TMJs and muscles of mastication for tenderness,
assess jaw movement for clicking, deviation, locking.
Investigations\: diagnosis mainly clinical; ESR and CRP for in
soft tissue views of TMJ.
Management goals\: eliminate pain, restore normal jaw function; most cases managed conservatively, few require surgery.
Conservative management\: identify problem habits, jaw exercises, analgesia (paracetamol, NSAIDs), antidepressants,
occlusal splint, physiotherapy, acupuncture (evidence inconclusive).
Surgical management\: considered when conservative measures fail; includes arthrocentesis, arthroplasty, TMJ
replacement surgery (rare).
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Introduction
Temporomandibular dysfunction (TMD) refers to a range of disorders causing pain in the pre-auricular area and muscles
of mastication.
It is the most common non-dental cause of orofacial pain and often associated with other chronic pain disorders.
Aetiology
Anatomy
The temporomandibular joint (TMJ) connects the skull to the lower jaw. The TMJ comprises the following structures\:
Mandibular fossa of the temporal bone
Articular disc
Mandibular condyle
Supporting ligaments
The superior compartment of the TMJ is responsible for the translational movement of the joint.
The inferior compartment of the TMJ is responsible for the rotational movements of the joint.
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Figure 1.An illustration of the TMJ. The meniscus of the TMJ is located between the head of the mandibular condyle and the glenoid
fossa of the temporal bone and can contribute to clicking and locking of the joint.
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Causes of TMD
TMD involves multifactorial pathophysiology and there is no conclusive theory on the exact cause of the condition.
Possible underlying causes include\:
Stress
Low mood
Bruxism (tooth grinding)
Co-morbidities\: including chronic pain (e.g.
Trauma to the teeth/face causing malocclusion (an abnormal bite)
Clinical features
History
Typical symptoms of TMD include\:
Pain in the pre-auricular area which can radiate to the jaw and temporal region
Clicking sounds\: due to crepitus of the TMJ joint
Locking\: as a result of the articular disc becoming trapped preventing the jaw from closing
Trismus\: di
Clinical examination
Typical clinical signs of TMD include\:
Tenderness on palpation of the TMJ
Tenderness at the insertion point of masseter and temporalis
Crepitus of the TMJ during jaw movement
Trismus
Locking of the jaw
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Examining the TMJ
Begin by inspecting the mouth to look for dental pathology and to assess the patient's occlusion (bite).
Palpate the TMJs bilaterally and then the muscles of mastication to identify any tenderness.
Ask the patient to open and close their mouth whilst palpating the joint to detect clicking as a result of joint crepitus.
Deviation or locking of the jaw may also be observed at this point.
Investigations
In most cases, the diagnosis of TMD is clinical, with no further investigations required.
Relevant investigations which may be performed in a minority of cases include\:
ESR and CRP\: to assess for evidence of in
X-ray\: to identify gross bony pathology
MRI\: provides detailed views of the soft tissues of the TMJ (e.g. intra-articular disc)
Management
The primary goals of treatment are to eliminate pain and restore normal jaw function.
Most cases can be managed conservatively with only a small minority requiring surgical management.
Patient education is important. It is important to reassure patients that most cases of TMD are benign and will improve with
conservative management. The British Association of Oral Surgeons has produced a patient information lea explaining
TMD.
Conservative management
Conservative management of TMD includes\:
Identi
Jaw exercises to strengthen muscles of mastication
Analgesia\: paracetamol and NSAIDs
Antidepressants
Occlusal splint\: a bite guard worn over the teeth to help with malocclusion or bruxism
Physiotherapy\: improves joint function through jaw stretch and muscle relaxation
Acupuncture\: may be helpful, although evidence is inconclusive
Surgical management
Surgical management is only considered in a small number of cases when conservative measures have failed to control
the patient's symptoms.
Some examples of surgical intervention include\:
Arthrocentesis
Arthroplasty
TMJ replacement surgery (exceedingly rare)
References
Dwonkin SF. The OPPERA study\: Act One. J pain 2011; 12\: T1-T3
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Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular Disorders. BMJ2015;350\:h4154
Ghurye S, McMillan R. Pain-Related Temporomandibular Disorder – Current Perspectives and Evidence-Based
Management. Dental Update 2015; 42 (6)\: 533-546
OpenStax. T M J . License\: [CC-BY]
Related notes
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Contents
Introduction
Aetiology
Clinical features
Investigations
Management
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