What are TMDs?

History:

	TMJ anatomy:
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Functional Anatomy:

1. Innervation:

   

	Clinical criteria for temporomandibular disorders:
	Facial pain
	Motion: limitation Deviation
	Noise: Clicking (Popping) Crepitus
	Tenderness

Motion:  

Range of motion 1- Active Range Of Motion (AROM):  It’s the opening under voluntary effort , it is measured by the distance between upper central incisors and lower central incisors. Normal…………………>40 mm Restricted…………….   Male if less than 35 mm.    Female if less than 30 mm. Excessive……… it should be  considered  normal except when there is a history of locking or there is a pain or discomfort during opening that interfere  with normal function 2-Passive Range Of Motion (PROM) : +(2-3mm) Deviation As the both sides are not affected to the same  extend usually deviation occurs toward the affected side.

Pain:         Pain Diary:

TMD Classification:

Non-inflammatory articular disorders :

        1-Disk displacement:

                  It’s derangement  of the condyle disc relationship arises from elongation of disc ligament and thing of the posterior border of the disc so the disc assumes an anterior position to the condyle.

Types of disc displacement: With reduction Without reduction •Pain • • •Pain Noise  : reciprocal clicking         N.B : closing click near the intercuspal position Noise: no joint noise but some times there is fine crepitus . Motion: no limitation  N.B. slight deviation during  opening     Motion :limited mouth opening. N.B : AROM = PROM   2-Deviation in form: •    Due to actual changes in the shape of articular surfaces (disc, condyle and/or fossa) •Clinical criteria :  Pain                         motion :normal                         Noise: reciprocal and repetitive clicking N.B with change in the speed and the force of jaw opening the click occurs at the same place.                                            Tenderness : no 3-Hyper mobility and Dislocation:    A-hypermobility: •Excessive disc and/or condyle translation usually beyond the eminence •Usually associated  with eminence that has  steep short posterior slope followed by a longer anterior slope and the associated occlusion characterized deep  overbite. •Clinical criteria  : Pain ……… usually no pain unless it becomes habitual.                                       Tenderness ……. No                                                                              Noise………thud (jump forward to wide opening position )or                                                           popping on wide opening sometimes clicking and                                                           this does not occur in lateral excursion.                                          motion …….excessive and deviation near the max. opening may                                                           present •  N.B. subluxation is a repeatable phenomenon that occur at the same position even in different speed and force the position does not change              If there is clicking it disappear  with function             B-Dislocation (open lock):              A condition in which the condyle is positioned anterior to articular eminence and can not return to closed position • •Diagnostic criteria : inability to close the mandible with  pain at the time of dislocation and residual  pain after reduction , trismus usually associated . • •When the patient can reduce the mandible by himself it is called hypermobility. •   Ankylosis:   •      It is a condition in which fusion of the condyle ,disk and fossa complex occurs as a result of formation of fibrous tissue, bone fusion or a combination of the two.                                                                                                                                                                                                                                            •Ankylosis may be fibrous or bony •Clinical criteria                         pain……………no pain                       noise………….no joint noise                       motion…………marked restriction of mandibular                       movement  with deviation to the affected side        Inflammatory articular disorder: 1-Synovitis and capsulitis •cannot be differentiated clinically , though not valuable in treatment. •Occurs due to spread of inflammation from adjacent structures , infection or trauma 2-arthritides         a- osteoarthrosis                b- osteoarthritis                c- polyarthritides   NON ARTICULAR TMDs:    Keys in differential diagnosis: 1-History                   2-Mandibular restriction 3-Mandibular interference 4-Loading the joint 5-Anathetic blockade                  CASE REPORTS   CASE 1   •CHIEF COMPLAINT: • A 22 years  old patient was complaining from left sided TMJ pain and clicking .The problem began 2 months previously, after the patient was hit on the jaw. The clicking then started. The pain is well localized over the TMJ and was worse on eating or talking. • •HOW TO DIAGNOSE (in steps)     1-Pain : localized         2-joint noise: Opening click at 16mm and a closing click at 4mm          3- range of motion : The patient opened to 40mm with deviation towards the left until the opening click occurred . The mandible then shifted towards the midline.          4-Tenderness: The left TMJ was tender to palpation and there was left sided muscle                                    tenderness   •What is the diagnosis??   •Case 2: Chief complaint : Inability to open the mouth wide •Past History : Noise in the right joint for the past 6 weeks which disappeared suddenly during yawning . Sharp pain  on locking as voluntary opening decreased . Persistent pain dull and aching. • •How to Diagnose? •1-Pain: Sharp pain on locking •2-Noise: not present •3-Motion: opening 30mm with deviation of the mandible to the right •4-Tenderness: localized tenderness of the right TMJ • •What is the diagnosis??       •Case 3: Chief complaint: limited voluntary opening , chronic pain in the left joint ,headache •Past history : Grating sounds in the left joint over the past year , recurrent dull pain that wakes the patient at night • •How to diagnose? •1-Pain : recurrent spontaneous dull pain •2-Noise: grating noise •3-Motion: limited with deviation to the left on opening •4-Tenderness: present in the left shoulder , neck and the masticatory muscle • •N.B.TMJ radiograph positive for joint erosion • •What is the diagnosis??