TMJ Disorders

Author Credentials 

Marc Gibber, MD
Director, General Otolaryngology
Department of Otolaryngology-Head and Neck Surgery
Montefiore Medical Center
Bronx, NY

Module Summary

Disorders of the temporomandibular joint are relatively common, presenting in 5-15% of the general population. There are two distinct anatomic causes of TMJ disorders, those caused by injury to the myofascial structures and those caused by injury to the joint itself, it is crucial to be able to identify the source of the symptoms as the treatment options differ based on the source. Workup and management of TMJ disorders depend on severity and location of the symptoms and range from conservative treatment with oral and topical medications combined with oral therapy to oral devices and rehab to surgical intervention. The treatment of TMJ disorders usually involves Otolaryngologist, Maxillofacial surgeons, dentist and prosthodontist.

Module Learning Objectives 
  1. Review pathology physiology of TMJ disorders.
  2. Describe proper physical exam, diagnostic testing and management of TMJ disorder.
  3. Explain medical and surgical treatment of TMJ disorders.

Embryology

Learning Objectives 

To understand the embryologic development of the TMJ, and the development of the mandible and temporal bone.

References 
  1. Sharawy M. Developmental and clinical anatomy and physiology of the temporomandibular joint, In Fonseca R, ed. Oral and maxillofacial surgery. Philadelphia , PA: Saunders, 2000:3-19.

Anatomy

Learning Objectives 
  1. To understand the anatomy of the temporomandibular joint and the anatomic relationship between the temporal bone and mandible.
  2. To understand the relationship of the temporomandibular joint to the surrounding musculature, specifically the muscles of mastication.
References 
  1. Sharawy M. Developmental and clinical anatomy and physiology of the temporomandibular joint, In Fonseca R, ed. Oral and maxillofacial surgery. Philadelphia , PA: Saunders, 2000:3-19.

Pathogenesis

Learning Objectives 
  1. Understanding the pathophysiology of TMJ disorders.
  2. Understanding the difference between myofascial disorders and disorders of the joint.
  3. Understanding Wilkes classification system.
References 

Wilkes CH. Internal derangement of the temporomandibular joint pathologic variations. Arch Otolaryngol Head and Neck Surg. 1989;115:469-477.

Incidence

Learning Objectives 

To understand the prevalence of TMJ disorders.

References 
  1. Pow EH, Leung KC, McMillan AS. Prevalence of symptoms associated with temporomandibular disorders in Hong Kong Chinese. J Orofac Pain. 2002;15(3):228-34.

Genetics

Learning Objectives 

To understand the genetic components that controbute to TMJ.

References 
  1. Smith SB, Maixner D, Greenspan J, et al. Potential Genetic Risk Factors for Chronic TMD: Genetic Associations from the OPPERA Case Control Study. The Journal of Pain. 2011;12(11 Suppl):T92-101. 
     

Patient Evaluation

Learning Objectives 

Understanding the proper technique to evaluate TMJ disorders.

References 
  1. Bates B, Bickley LS, Hockelman RA, Physical examination and history taking, 6th ed, Philadelphia, PA: Lippincott, 1995: 505-510.

Measurement of Functional Status

Learning Objectives 

Understanding the classification system associated with functional status in patients with TMJ disorders.

References 
  1. Wilkes CH. Internal derangement of the temporomandibular joint pathologic variations. Arch Otolaryngol Head and Neck Surg. 1989; 115:469-477.

Imaging

Learning Objectives 
  1. Understanding the utility of the different radiological tools for assessment of TMJ disorders.
  2. Identifying the pros and cons of plain films, CT and MRI in the work-up of TMJ disorders. 
References 
  1. Bag AK, Gaddikeri S, Singhal A, et al. Imaging of the temporomandibular joint: An update. World J Radiol. 2014;6(8):567-582. 
     

Pathology

Learning Objectives 
  1. To understand the varying pathology surrounding TMJ disorders and the causes of hyper and hypo mobile disorders.
  2. To identify histological changes within the temporomandibular joint in patients with chronic inflammatory changes.
References 
  1. Murphy MK, MacBarb RF, Wong ME, Athanasiou KA. Temporomandibular Joint Disorders: A Review of Etiology, Clinical Management, and Tissue Engineering Strategies. Int J Oral Maxillofac Implants. 2013;28(6):e393-414.

Treatment

Learning Objectives 

To understand the wide-ranging options available for treatment of TMJ disorders and how they apply to individual conditions.
 

Medical Therapies

Learning Objectives 

To appreciate the different medical therapy options for TMJ disorders including oral, topical and injectable medications and treatments.

References 
  1. Syrop S. Pharmacologic management of myofascial pain and dysfunction. Oral Maxillofac Surg Clin North Am. 1995;7:87-97. 
  2. Karakalar A. Yilmaz N, Bilgici A. et al. Botulinum toxin for the treatment of temporomandibular joint disk disfigurement: clinical experience. J Craniofac Surg. 2005;16(3):476-481. 

Surgical Therapies

Learning Objectives 
  1. To understand the surgical options available for TMJ disorders.
  2. To identify appropriate patients for surgical intervention.
References 
  1. Nitzan DW. Dolwick ME Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991;49:1167. 
  2. Hall HD, Indresano T, Kirk WS, et al. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg 2005;63:1174. 

Rehabilitation

Learning Objectives 
  1. To understand the varying rehabilitation therapies available for TMJ disorders.
  2. To appreciate the oral appliances available to patients with TMJ disorders.
References 
  1. Al-Ani MZ. Gray RJ, Davies SJ, et al. Stabilization splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev 2004; 1 
  2. Rugh JD. Home care and behavioral therapy. In: McNeill C, ed. Current controversies in temporomandibular disorders. Chicago, IL: Quintessence Publishing. 1992:149-152. 

Case Studies

  1. A 54-year-old male with hx of left condylar fracture 18 months prior presents with 6 months of trismus, left ear pain radiating to his jaw and the feeling that his bite is off.
  2. A 41-year-old female presents with two years of constant clicking of her right jaw every time she chews or yawns and on and off pain of her right facial region.

Complications

Learning Objectives 

To understand the long-term complications of TMJ disorders and potential consequences from the procedures that are used to treat these disorders.

References 
  1. Vallerand WP, Dolwick MF. Complications of temporomandibular joint surgery. Oral Maxillofac Surg Clin N Am. 1990;2:481-488. 

Review

Review Questions 
  1. What percentage of the population experiences disorders of the TMJ?
  2. Name some co-morbidities associated with TMJ disorders?
  3. Name the five stages of internal derangement in the Wilkes classification system?
  4. Name the benefits of CT and MRI in the workup of TMJ disorders?
  5. Describe appropriate patients for medical and surgical management of TMJ disorders?
Resources 

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  1. Annual Meeting Webcast (AMW):