tmj disorders

ATMJ Disorder

The TMJ is diarthroidal articulation between the condyle of the mandible &the squamous portion of the temporal bone . It is a true synovial joint & has much in common with other synovial joint of the body but have several anatomic & functional characteristic that distinguished it from most other joint
1-the articulating surfaces of the bones are covered by an a vascular fibrous connective tissue that may contain a variable number of cartilage cells & thus can be designated fibro cartilage
2-The articulating complexes of bone carry teeth .The shape of teeth & position influence the movement of the joint . It is the only joint with a rigid end point of closure
3-It has bilateral articulation with cranium , so the left & right articulation must work together .
4-The TMJ is a complex joint because each joint has an articular disc (meniscus ) interposed between the condyle &the temporal bone .
Lateral aspect of the TMJ :
Glenoid Fossa:
The mandibular condyle articulates at the base of the cranium with the squamous portion of the temporal bone. This is called as the glenoid fossa.
Articular Disc :
It is composed of dense fibrous connective tissue devoid of any blood vessels or nerve fibers. Intermediate zone: In the sagittal plane, it can be divided into three regions according to thickness. The central area is the thinnest and is called as intermediate zone. Both anterior and posterior to the intermediate zone, the disc becomes considerably thicker. The posterior border is generally slightly thicker than the anterior border

Anterior view: From the anterior view, the disc is generally thicker medially than laterally. The precise shape of the disc is determined by the morphology of the condyle and mandibular fossa

Retrodiscal tissue and lamina:

The articular disc is attached posteriorly to an area of loose connective tissue that is highly vascularized and innervated, it is called as retrodiscal tissue. Superiorly, it is bordered by the lamina of connective tissue, which contains many elastic fibers, the superior retrodiscal lamina. This gives necessary freedom for anterior movement of the disc. Since this region consists of two areas, it is called as bilaminar zone
The articular disc is attached to the capsular ligament anteriorly, posteriorly as well as medially and laterally. This divides the joint into two distinct cavities ; the upper or superior cavity which is bordered by the glenoid fossa and superior surface of the disc and the lower or inferior cavity, which is bordered by the mandibular condyle and inferior surface of the disc.

Ligamentous Structures :

Collateral ligaments The collateral ligaments attach the medial and lateral borders of the articular disc to the poles of the condyle. It is commonly called as discal ligament and are two in number. The medial one attaches the medial edge of the disc to the medial pole of the condyle and the lateral one, attaches to the lateral edge of the disc to the lateral pole of the condyle . Their function is to restrict the movement of the disc away from the condyle, as it glides anteriorly and posteriorly.


Capsular ligament :The entire TMJ is surrounded and encompassed by the capsular ligament. The fibres of the capsular ligament are attached superiorly to the temporal bone, along the border of the articular surface of the mandibular fossa and articular eminence. Inferiorly, the fibres are attached to the neck of the condyle. The internal surface of the cavity is surrounded by specialized endothelial cells that form the synovial lining. This lining along with a specialized synovial lining located at the anterior border of the retrodiscal tissue produce the synovial fluid, which fills both the joint cavities. Thus, TMJ is referred to as a synovial joint. It acts to resist any medial, lateral or inferior forces that tend to separate or dislocate the articular surface. Another function is to encompass the joint, thus retaining the synovial fluid.

Temporomandibular ligament :It is also called as lateral ligament as it is located laterally to the joint. It is composed of two parts, an outer oblique portion and an inner horizontal portion. The outer portion extends from the outer surface of the articular tubercle and zygomatic process, poster inferiorly to the outer surface of the condylar neck. The inner horizontal portion extends from the outer surface of the articular tubercle and zygomatic process posteriorly and horizontally to the lateral pole of the condyle and posterior part of the articular disc. The oblique portion of the ligament resists excessive dropping of the condyle and therefore, acts to limit the extent of mouth opening.
Sphenomandibular ligament: It is attached to the spine of the sphenoid bone and extends downwards and laterally to the small bony prominence on the medial surface of the ramus of the mandible, called the lingula. It does not have any significant effect on mandibular movement.

Stylomandibular ligament: It arises from the styloid process and extends downward and forward to the angle and posterior border of the ramus of the mandible. It becomes taut when mandible is protruded but is most relaxed when the mandible is opened. Its function is to limit the excessive protrusive movements of mandible .

Mandibular malleolar ligament: Actually, the mandibular malleolar ligament consists of fibroelastic tissue with some ligamentous qualities. It originates from the neck and anterior process of malleus and is inserted on the medioposterior and superior part of the capsule, interarticular disc and sphenomandibular ligament

Synovial Fluid

The passive volume of upper and lower joint cavity is 1.2 and 0.8 mL, respectively. A small amount of a clear , straw colored viscous fluid is found in the articular spaces, which is known as synovial fluid. It is secreted by synovial membrane lining the articular disc, the capsule and also by retrodiscal tissue lining. Synovial fluid is characterized by well-defined physical properties of viscosity, elasticity and plasticity. It contains small population of varying cell type such as monocytes, lymphocytes, free synovial cells and occasionally polymorphonuclear leukocytes. The chemical composition of synovial fluid indicates that it is dialysate of plasma, with some added protein and mucin. It is a lubricant and reduces the mechanical friction between the condyle and the articular disc and the mandibular fossa and articular disc. It is also a nutritional fluid for the a vascular tissues covering the condyle and the articular tubercle and also for the disc. It is elaborated by diffusion from the rich capillary network of the synovial membrane, augmented by mucin secreted by the synovial cells.

Vascular supply: It comes from the branches of the superficial temporal arteries, deep auricular arteries, anterior tympanic arteries and ascending pharyngeal arteries
Nerve supply: It is innervated by the branches of auriculotemporal nerve, masseteric nerve and the posterior deep temporal nerve, which are branches of the mandibular portion of the trigeminal nerve.

Functional Movement of TMJ

Elevation (jaw closing): The mandibular elevators include the coordinated functions of masseter, temporal and medial pterygoid muscle of both the sides. Temporalis maintains the physiological rest position of the mandible. The posterior fibers of temporalis retract the head of mandible while closing the mouth.

Depression: The depression of mandible includes the activity of the lateral pterygoid and the suprahyoid muscles. The inferior head of the lateral pterygoid is the main muscle used for depressing the mandible. The superior head of the lateral pterygoid pulls the articular disc forward, creating the glenoid joint activity. The suprahyoid group of muscles also acts in mandibular movement; by initiating and assisting opening of the jaw. The lateral pterygoid muscle has a major role, particularly when the mouth is opened wide or against resistance by the digastric, geniohyoid and mylohyoid muscle. The infrahyoid group of muscles participates in the activity by fixing the hyoid group to exert a downward pull on the mandible.
Protrusion: It is performed by the medial and lateral pterygoid muscle of both the sides
Retrusion : It is performed by the posterior fibers of temporalis and digastric muscle.
Lateral excursive movements: In this type of movement, the medial pterygoid and lateral pterygoid of each side, act alternately. If the mandible is moved to the right side the medial pterygoid of right side and the lateral pterygoid of left side act simultaneously
Diseases of the TMJ:
1-Intracapsular disorder.
A-developmental.
Disorder in this category are not common & include
1- agenesis of the condyle ,( unilateral or bilateral): There are free movement (eccentric movement) anterior open bite, asymmetry of face, altered occlusion. Mastication may be difficult, Shift of mandible towards the affected side occurs during opening in unilateral type, but it is absent in bilateral type . It is frequently associated with other anomalies like defective and absent external ear, an underdeveloped mandibular ramus or macrostomia
2- Hypoplasia of the condyle: It is the underdevelopment of mandibular condyle which can be congenital or acquired . The clinical Features of unilateral Hypoplasia, on the unaffected side, there is elongation of the body of mandible and flat appearance of the face. Body of mandible is short on affected side . Mandible shift towards the affected side on opening. Malocclusion is present. There may be cross bite on the affected side. Eruption of teeth may be delayed in case of hypoplasia of the condyle. In some cases, it will cause impacted and unerupted teeth. While The clinical Features of bilateral Hypoplasia, Due to lack of mandibular growth, micrognathia with the chin retruded to the level of hyoid bone occurs. There is delayed eruption of teeth on the both side, Patient is having class II malocclusion.
3-Hyperplasia of the condyle: It is rare disorder which is characterized by excessive growth of condyles. It may occur due to trauma during the birth, some tumors like chondroma, osteochondroma or osteoma of condyle can lead to hyperplasia of condyle .
Fibrous dysplasia, Paget’s disease which affects the bones, may affect the condyle leading to its overgrowth , also Condylar hyperplasia can be seen in hereditary
Syndrome. Most common age of occurrence is 15 to 19 years. Unilateral type, it can affect only one condyle. There is progressive enlargement of the mandible on the affected side and give rise to facial asymmetry on that side shifting of the midline of chin to the unaffected side , cross bite, open bite, and asymmetric protrusion on the affected side. While the clinical feature of bilateral hyperplasia mandible is larger on both side and is placed more forward than the maxilla. This will result in anterior cross bite

The signs & symptoms of these disorders appear as
Limitation in the mandibula opening & pain as in the hyperplasia of the condyle .
Freedom of eccentric excursions as in the hypoplasia of the condyle .
Anterior open bite &inability to close repeatedly to fixed retruted position in agenesis of the condyle .
Asymmetry of the face & deviation during opening

Diagnosis by radiograph & treated by surgery.


B-infectious disorders
It is also called as ‘septic arthritis’. It may be acute or chronic it may due to.
• Microorganisms: It is caused by direct spread of organisms like staphylococci, streptococci, pneumococci and gonococci, from an infected mastoid process, tympanic cavity or via blood.
• Infection from a maxillary molar and parotid gland.
• Osteomyelitis and middle ear infection: It is acute in nature.It can be caused by osteomyelitis and suppurative middle ear infection.
Signs & symptoms :
It usually occurs in young children with no sex predilection . It is always unilateral. In some cases bilateral involvement can occur. There is severe pain on jaw movement , with an inability to place the teeth in occlusion, due to presence of infection in the joint. Redness and swelling over the joint. In some cases, swelling may be fluctuant and extend beyond the region of the joint. Tender cervical lymph nodes on the side of infection. This helps to distinguish septic arthritis from other TMJ disorders.

Diagnosis by history &clinical examination . Radiograph is of limited value

Treatment by antibiotic ,analgesic & soft diet

c-Traumatic disorders :

Injury to the TMJ may lead to the damage to the soft tissues(capsular ligament ,disk ,synovial membrane) These injury may cause by over extension during opening like yawing or fallowing dental trauma . Fracture of the condyle occurs frequently &characterized by pain ,asymmetry of the face ,swelling ,limitation in movement &deviation to the affected side during opening.
Subluxation : it is the anterior position of the head of the condyle to the articular eminence & the patient can retrude his mandible back ward into the normal position by physiological activity ,it is may be unilateral or bilateral . It may be due to Long continuous opening of mouth in the dental chair or singing, yawning and excessive movement apparently causes stretching of the joint ligament or rupture of the external pterygoid attachment to the meniscus. It may follow the chronic degenerative changes of osteoarthritis. The clinical features of subluxation the condyle may get locked when the mouth is opened widely and upon closing, accompanied by a sound caused by movement of the condyle over the articular eminence. On palpation ‘click’ on opening and sliding of condyle over the articular eminence are common. The treatment of subluxation by Conservative method: Here, the objective is to achieve shrinkage of the capsule by a sclerosing agent, which will cause fibrosis of the capsule. It will limit the condylar excursion without deleterious effects on motion and cartilaginous part of the articulating surface of the condyle. The solution used is 5% sodium psylliate . It may be necessary to repeat the injection every 2 to 3 weeks, till fibrosis occurs. Also may be treated by surgery: Insertion of bone graft is done. The joint is exposed; a vertical incision is made in the outer side of the capsule. The edges are overlapped and then sutured so as to tighten the capsule in the anteroposterior plane. After 7 days of intermaxillary fixation, clicking and subluxation will be relieved. Shortening of the temporalis tendon also relieves subluxation.

Dislocation : it is the anterior position of the head of the condyle to the articular eminence & the patient can't retrude his mandible back ward into the normal position by physiological activity ,it is may be unilateral or bilateral .
The clinical feature dislocation :
Patient has great difficulty in swallowing and saliva drools over the chin. Pain in the region of temporal fossa and there is a depression where the condylar head is normally situated. The mandible is postured forward and movement is extremely limited. The condyle becomes locked anterior to the articular eminence and is prevented from sliding back by muscular spasm. When unilateral dislocation occurs, the teeth will be gagged posteriorly on the side of dislocation and the chin will be deviated towards the normal side. Reduction of dislocation: It can be done by the following:– Manipulation without anesthesia: Some type of sedation
should be given to the patient before manipulation. Patient should be sitting on the chair with the operator in front. The thumbs covered with gloves should be pressed down over the buccal shelf area of the mandible, near the lower molar teeth and at the same time elevating the chin with fingers and pushing the entire mandible posteriorly and then upwards.

Ankylosis:

is one of complication of trauma or infection involving the TMJ .It may be fibrous or bony & unilateral or bilateral . It is seen primarily in a young age or between 1 to 10years . Pain and trismus are the most common symptom which is directly related to the duration of ankylosis. Patient also complaint of reduced mouth opening. There may be poor oral hygiene, carious teeth and periodontal problems malocclusion, depending upon the duration. Unilateral ankylosis is more common than bilateral ankylosis. Mouth opening is impossible, but the patient may be able to produce several millimeter of interincisal opening .The clinical appearance as asymmetry of the face with fullness on the affected side and relative flattening on the unaffected side. In unilateral ankylosis, patient’s face is deviated towards the affected side. Cross bite is present due to deviation of mandible and shifting of midline.


While in the bilateral ankylosis Face is symmetrical with micrognathia.There is bird face appearance . Due to long standing ankylosis, atrophy or fibrosis of muscles of mastication may result.

Diagnosis by radiograph(absence of joint space) & treated by surgery .

Management of ankylosis :
Brisement force: Forceful opening of the jaws under general
anesthesia.
• Condylectomy: Condyle is excised.
• Gap arthroplasty:
It is performed in the mandibular neck.Two parallel lines are cut, beginning in depth of the sigmoid notch and carried downwards at an angle of 45 degree at the posterior border of the ascending ramus.

Perforation of the disc : it may result from excessive pressure resulting in pain joint noises . Diagnosed by arthrography

D-inflammatory disorders

1- rheumatoid arthritis : It is a debilitating systemic disease of unknown origin, characterized by progressive involvement of the joint, particularly bilateral involvement of large joints. Bony components of the TMJ are affected secondary to the granulomatous involvement of the synovial membrane that subsequently spreads to the articular surface of the condyle. It is non-suppurative inflammatory destruction of joint. its highest incidence in women from 20 to 50 years of age. In typical cases, small joints of fingers and toes are
the first to be affected. Swelling of the proximal but not the distal, interphalangeal joints give the finger as spindle-like appearance . Symptoms include bilateral stiffness, crepitus,
tenderness and swelling over the joint. Fever, malaise, fatigue, weight loss, pain and stiffness in the limb are also evident.
Clinical presentation
*usually affect the middle aged group &female more than male .
* In typical cases, small joints of fingers and toes are the first to be affected. Swelling of the proximal but not the distal, interphalangeal joints give the finger as spindle-like
appearance
* Symptoms include bilateral stiffness, crepitus, tenderness and swelling over the joint. Fever, malaise, fatigue, weight loss, pain and stiffness in the limb are also evident.
* Subcutaneous or rheumatoid nodules: There is formation of subcutaneous nodules on the pressure points, sites of friction and various vascular lesions, both necrotizing and obliterative types.


TMJ involvement
In acute cases, there is bilateral stiffness, deep seated pain, tenderness on palpation and swelling over the joint. There is limitation in opening of mouth.
Pain on biting is referred to the temporal region, ear and angle of mandible.
In chronic cases, crepitus is the most frequent finding. Functional disturbances like deviation on opening and inability to perform lateral excursions are common.
Anterior open bite is present due to bilateral destruction and anteroposterior positioning of the condyle.
Fibrous ankylosis of the joint which may be partial or complex occurs in long term.
Subluxation, secondary arthritis, muscular atrophy, and bird-like face can occur

Radio graphical changes include at early stage of the disease there is thickening of the synovial membrane & fluid accumulation leading to pain without radiographical changes (pannus reaction ) . The pannus may destroy the disc and due to this, the joint space may reduce slightly or substantially, depending on the severity of the condition and the length
of time.
There is flattening of the head of the condyle. Erosion of the condyle can be seen . Bone destruction which occurs in articular eminence may be slight or confined to the posterior
surface or to the inferior convexity. Most of the eminence may be destroyed in severe long continued cases. As the disease continues, the condylar outline becomes increasingly irregular and ragged. In most severe cases, condyle may be completely resorbed, resulting in loss of vertical support and anterior open bite. In advanced stages, erosion of anterior and posterior condylar surface at the attachment of the synovial lining occurs, which may resemble a ‘sharpened pencil’

Treatment:

Adequate rest to the joint, soft diet is advocated.
Intra-articular corticosteroid injections: Local injection of long-acting steroids such as methylprednisone acetate (20-80) for large joint and 4–10 mg for small joint) or triamcinolone hexa-acetomide (10–40 mg for large joint and 2–6 mg for small joint) are given.
Nonsteroidal anti-inflammatory drugs: These drugs are inhibitory to prostaglandins. These are used for symptomatic relief. Salicylates (for pain) and anti-inflammatory agents like indomethacin, ibuprofen, diclofenac and piroxicam can be used.
Azathioprine is found to be effective in both, high and low doses .
Slow-acting antirheumatic drugs: These are the antimalarials like hydroxyl chloroquine sulfate, sulfasalazine (500) mg/day and methotrexate .
Local treatment: It is done with heat, diathermy, jaw exercise or a mouth stretcher. Muscle strengthening exercise and hydrotherapy.
Surgical synovectomy: It accounts for removal of synovial membrane which is responsible for enzymatic destruction of cartilage


2-Psoriatic Arthritis:
It is a chronic disease of unknown etiology characterized by skin lesions and sometimes joint involvement. Skin lesions are found on the trunk, arms, face and scalp. Skin lesions exhibit broad irregular papules or plaques, which are dull red to brownish in color and are usually covered with a layer of fine silvery scales . When scraped, they leave behind small bleeding points: this is called as Auspitz’s sign. When there are TMJ involvement the main symptom is pain, which is usually unilateral. There is difficulty in opening the mouth . TMJ is tender. Crepitus, deviation towards the affected side and in small proportion of cases, deformities are seen .

3-Osteoarithritis :

It is also called as ‘osteoarthrosis’ or ‘degenerative arthritis’.It is primarily a disorder of movable joints characterized by deterioration and abrasion of the articular cartilage with
formation of new bone at the joint surface. There is destruction of the soft tissue component of the joint and subsequent erosion with hypertrophic changes in bone. There is breakdown of the connective tissue covering the condyle, articular eminence and the disc. Recently, there are some evidences suggesting that there are some inflammatory components present in osteoarthritis.

Etiopathogenesis; Overload to joint: The lesion is brought by an increase in the functional demands of the healthy tissue due to repetitive overload on joint. This will result in breakdown of the joint . Deterioration of functional capacity of joint: There may be
normal load to the joint but functional capacity is reduced as a part of aging. By another theory, bone growth does not cease completely after puberty and remodeling of the
joint progresses under functional demands. Degenerative joint disease may develop when the remodeling rate of bone exceeds that of the cartilaginous repair. The gross evidence
of these changes is the formation of marginal osteophytes with development of new bone in the area adjacent to the cartilage.

Clinical presentation :

It occurs in patients older than 40 years of age and 85% of them are older than 70, with a mean age of 53 years. Females are affected 6 times as frequently as males.
It is common in many joints, but it is not frequently found in TMJ.
There is unilateral pain over the joint, which may be sensitive to palpation. Patient also experience pain on movements or biting, which may limit mandibular function.
Pain usually worse in the evening.
There is deviation of the jaw towards the affected side. Affected joint is swollen and warm to touch. Stiffness of the joint.
There is presence of crepitation of the joint, the sound indicates degeneration within the articulating surfaces of the joint or disc.
There is limitation of jaw movements, which becomes increasingly apparent with function .
Early signs may progress to spasm of the masticatory muscles resulting in stiffness and locking of the jaw. If not treated at this stage, it may lead to irreversible changes in the TMJ.


Radiographic Features:
First evidence of erosion of condyle on a radiograph occurs on an average, 6 months after the onset of TMJ pain. This will result in enlargement and shallowing of mandibular fossa, Density is increased as a result of sclerosis. Flattened articular eminence and Development of lipping (shell-like extension) on the anterior borders
Treatment:
Elimination of the cause: It includes occlusal adjustment or replacement of the missing teeth and ill fitting prosthesis,
Relieving the pressure on joint: Occlusal adjustment and occlusal splints may reduce pressure on joint and relieve the symptoms.
Analgesic and anti-inflammatory drugs: For the relief of pain.
Heat therapy, ultrasonic , Muscle exercises and injection of local anesthetic in TMJ
Arthroscopic lavage may give relief in some patients

E-neoplastic diseases:

Intrinsic: It arises from the bone of the condyle, articular fossa and the joint capsule or th articular disc. It includes chondrosarcoma and synovial sac sarcoma.
Extrinsic: The tumors which extend from outside of TMJ, e.g.neoplasm of the parotid gland.
Signe and Symptoms: Pain on full opening of the mouth and diminished hearing. Swelling of the TMJ is present. Swelling may be huge to cause facial asymmetry. The tumor may be fixed to deep structures. Deviation of the mandible to the unaffected side. There is also malocclusion.

It can be treated by surgery, chemotherapy, radiotherapy and combination therapy

2- Extra capsular disorder:

Myofacial pain dysfunction syndrome (MPD),TMJ pain dysfunction syndrome (TMDs)

When muscle spasm develops, dysfunction as well as pain occurs and the condition usually is designated as MPDS. It is initiated as spasm of one or more masticatory muscle.


* prevalence:
It is quite common problem affecting the general population ,female more than male at a ratio of 2:1. Usually affecting young people at the age of ( 14-25) years but it can occurs at any age . usually affecting civilized people more often than ruler people .

*symptomatology:

1-masticotary pain : is a discomfort about the face & mouth induced by chewing &other jaw function .
2-joint sounds during mandibular movements .there are two types
a- clicking :single joint sound of short duration.
b-crepitation: multiple gravel like sound .

although the etiology of the clicking is not clearly understood but it may be due to

*uncoordinated contraction of upper &lower part of lateral pterygoid muscle
*anterior or posterior position of the articular disc
*organic changes within the component of the joint
3-restricted movement of the mandible
a-restricted mouth opening (normal 40mm)
b-limited lateral movement (5mm)
4-masticatary muscle tenderness &TMJ tenderness .
5-other less frequent signs &symptoms a-ear problem . Patient may complaint of tinnitus or otalgia (pain in ear) or toothache. The reason behind tinnitus is that bilateral molar loss causes distal condylar movement and direct pressure on the Eustachian tube with impingement on the auriculotemporal nerve, which is responsible for the ear symptoms, i.e. tinnitus.
b- salivary gland problem

* etiology:

Currently the accepted theories are fallowing (the out come of these theories is the myospasme leading to pain).


1-malocclusiontheory : it has proposed that malocclusion of the teeth result in condyle displacemen . it is pure mechanical theory &less acceptable
2-neuromuscular theory : functional disharmony between the TMJ &the dental occlusion is the etiolgy of the TMDs .
3-muscle theory : (Kraus1969) according to this theory the primary etiological factor lies in the muscle .
4-psychophysiological theory : according to these theory the muscle fatigue & spasm resulted from muscle hyperactivity which is initiated in (CNS ) & may be provoked by psycho physiological & social difficulties .

Causes of TMJs in Iraq:
(habit , extraction of posterior teeth , trauma to TMJ, malocclusion , osteoarthritis )

Diagnosis:

1- history :
(CC , HPI ,past medical history , past dental history ,social history ,psychological history )
2- clinical examination
inspection ( facial asymmetry ,scar ,mouth opening )-(intraoral teeth & soft tissue )
palpation (muscle of mastication & related muscle ,TMJ )

3- radiographic examination

Transcranial view
Transpharngyal view
Panoramic view
4-Arthrography : is the injection of contrast material into the synovial space fallowed by radiography of the joint ,used to .
* see the morphology & position of the disc
* presence of perforation or tear of the dsic
* presence of the adhesion of the disc
* presence of the loose body

Disadvantage of the arthrography
*invasive *exposure to radiation *hypersensitivity to contrast media
5-CT
6-MRI
7-EMG
8-cast sometime needed to analyze the occlusion
Differential diagnosis :
a- neural b- vascular c- skeleton muscle d- oral problem e-salivary gland f- ENT g- psychogenic h- Trotter syndrome (retropharyngeal tumor )


Treatment : the goal for management of TMJs are to
1- reduce the pain
2- restore normal joint function
According to the ADA there are many form of treatment used , but it must be notice that the order of the recommendation does not mean the priority sequence
* pharmacological therapy
* occlussal splint therapy
It is a removable appliance that fits over the occlusal & incisal surface of the teeth in one arch creating precise occlusal contact with the teeth of the opposing arch , it is commonly referred to as bite plat , night guard ,inter occlusal appliance .

TYPES OF OCCLUSAL SPLINTS:

* resieliant splint
* centric relation
* anterior repositioning splint
* anterior bite plan
* posterior bite plan
* pivoting splint

CENTRIC RELATION SPLINT :

A interocclusal appliance when it is in place , the condyles are in the most musculoskeletal stable position at the same time the teeth are contact evenly
Indication : it is used to treat muscle hyperactivity

ANTERIOR REPOSITIONING SPLINT :

A interocclusal appliance that encourages the mandible to assume a more anterior position .
The goal is to eliminate the sign & symptoms associated with disc interference
Indication :
- joint sound
- intermediate or chronic lock
- symptomatic treatment of inflammatory joint diseases


* physical therapy which is represent a group of supportive action for managing pain , these involve thermotherapy coolant therapy , massage therapy , electrical stimulation therapy ( transcutanuce electrical nerve stimulation ) relaxant therapy & EMG biofeedback

* exercise therapy : the objective of muscle exercise is to causes reflex relaxation of antagonistic muscle .It can be divided into
1- passive exercise
2- active exercise
- assist stretching
- resisted exercise
- clenching exercise

*surgical treatment

There are certain recommendation for treatment of patient with TMJ problem :

1- treatment should directed toward relaxation of the muscle

2- treatment must include several modalities since the problem of multifactorial etiology
3- treatment must include only reversible modalities
4- occlusal adjustment done only after
5- surgery involve the TMJ should not be done unless specific intracapsular organic problem can be identified