TMDs(1)

Prepared by:
dr/ akram alhemeary
we are going to talk about temporomandibular
disorders(TMDs) and their classifications.
This is a very hard and complicated topic for
under graduated students but we are
supposed to understand the general
classification of TMDs in this lecture and later
we’re going to discuss the clinical examination
of each disorder.
 *Classification of TMDs.
 *Examination of TMDs.
 *Etiology of TMDs.
 *Management of TMDs.
The classification of TMDs is referred to a scientist
called Aucisson who established it in 1996.

-Epidemiological data shows:

- that 50-75% of the population have signs of TMDs.
-20-25% have symptoms of TMDs.
-only 3-4% of the population seek treatment for TMDs.
(small minority, that’s why you underestimate TMDs).
- age range: 15-30 years-old ptns >> have dysfunctional
symptoms (like clicking, muscle tenderness etc.) so usually
dysfunctional symptoms associated with young age groups.
-Ptns who are older than 40 years have more commonly
degenerative joint disease (like osteoarithritis,
osteoarithrosis etc.)
-
 Internal derangement can occur at any age. It is a
problem between the condyle, disc, and glenoid
fossa.
 -Prevalence: male: female = 1:1 no predilection but
more females are seeking treatment compared to
males with 5:1 ratio.
 TMDs are multifactorial conditions that have
no single etiological factor. It could be due to
trauma, stress, genetics, parafunctional
habits, deep pain inputs, and occlusion (not
really a significant factor).
 Events that extend beyond the physiologic
tolerance of the ptn (like prolonged mouth
opening, stress, local anesthetic injection
etc.) will lead to TMDs at the end.
Occlusion is a variable factor across all ptns.
This means that there is no certain type of
malocclusion such as class II or class III
related or attributable to a certain type of
TMD.
Pain is the most common cause for the ptn to
seek treatment.
 50 % pf ptns reported to have parafunctional
habits.
 Muscle tenderness is frequently detected but
rarely reported, that means when you are
examining the ptn, he might feel some sort of
tenderness, but when you ask him about history
of pain, no pain experience would be recorded.
 Plane Radiography is the last tool used to
diagnose TMDs because it can’t show us soft
tissues. Also, it’s a 2D image (not 3D) which can’t
reveal the disease except when it is in an
advanced stage. (it only gives you information
when there is a big problem in bone).
 Joint noises:
 Clicking: happens with internal derangement (it’s a
popping sound associated with displacement or
dislocation meaning that the condyle and the disc are
not going together).
 Crepitus: happens when there is a problem with the
articular surfaces due to a degenerative disease.
 Locking: is occasionally reported.
 Trismus: the ptn usually complains of pain in his
muscles and limitation of jaw movements
particularly when he wakes up at morning, this is a
strong sign of parafunctional habits like sleep
bruxisim at night. Also, there is another type of
diurnal bruxisim at day time.
 Aucisson 1996 TMDS Classification

1.Masticatory muscles disorders.

*Protective muscle
cocontraction
*muscles soreness
*myofacial pain
*myospasm
*CNS mediated myalgia
*fibromyalga
2.Temperomandibular joint disorders.

*derangement of the condylar disc complex

*structural incompatibility of the articular surfaces
*inflammation
 3.Mandibular hypomobility.
*bone (sort of ankyloses whether fibrous or bone, or
a coronoid impedance).
*Muscular problem (Muscle contracture).
 4.Growth disorders.
The first group we will discuss is masticatory
muscles disorders and its categories

Protective cocontraction (muscle splinting):

-Ex: If you have injured your leg in a specific muscle, you

notice that there was pain and contraction in other near
muscles “coconraction protective response” this will allow
you to walk in a different way to reduce the feeling of pain.

-if not resolved it will continue to the second category which

is muscle soreness.
 -The key to know it is that the event has been
recent immediately follows an event. For
example, if you give your pt. an ID block then
he started to complain of pain in muscles
which are not related to the area you give the
anesthesia to, then it’s protective
cocontraction due to the deep pain.
 - Clinically : 1. Mild structural dysfunction (
reduced range and velocity of movements ) that
means when you ask your ptn to open his mouth
quickly , you will notice that he will open but
with a slow velocity and not fully.
 2. no pain at rest
 3. increased pain with function
 4. feeling of muscle weakness
 -If muscle cocontraction didn’t resolve since it
usually appears and subsides fast, then it will
continue as muscle soreness.
Muscle soreness: it’s the first response after a
prolonged /protracted muscle cocontraction .
Causes: 1. protracted muscle cocontraction
2. trauma
3. emotional stress
4. local injury
 Clinically:
 When you hear the history of your ptn he will say
that Pain began several hours to few days
following the event (like prolonged mouth
opening).Whereas, in muscle cocontraction pain
with function is reported directly/immediately
after the event .
 Structural derangement
 Minimum pain at rest
 Increased pain with function
 muscle weakness
 Local muscle tenderness

 Myofacial pain (trigger point myalgia):
 Causes: 1. Protracted local muscle soreness
 2. deep pain
 3. increased stress
 4. sleep disturbances
 5. local factors: habits, improper
postures, strain, ….
 6. systemic factors: hypovitaminosis,
fatigue, viral infection.
 *ex. when we palpate sternoclidomastoide, the
ptn feels pain in the molars area or in TMJ
(heterotopic pain).
 History: misleading history. (The pt comes to you
complaining of tension headache and it’s due to
trigger point in a muscle)
 Clinically: 1. Structural dysfunction
 2. pain at rest
 3. increased pain with function
 4. presence of trigger point
 Myospasm: involuntary CNS induced chronic muscle
contraction (in rest and function). Either due to local
factors (fatigue, electrolyte imbalance in the muscles)
or systemic factor like musculoskeletal disorder that
affects masticatory muscles.

 History: 1. sudden onset of pain

2. tightness
3. restriction in the jaw movements
associated with muscles rigidity. The ptn will complain
that he experienced a sudden pain with increased
tightness and he couldn’t move his jaw freely.
Clinically: 1. Structural dysfunction (marked
restriction in the range of jaw movements).
2. acute malocclusion (the ptn can’t
return into intercuspal position).
3. pain at rest
4. pain at function
5. local muscle tenderness
6. muscle tightness
Centrally mediated myalgia (chronic myositis):

History: long history of consistency of pain.

Clinically: 1. structural dysfunction
 2. pain at rest
 3. pain at function
 4. local tenderness, muscle
tightness and muscle contraction
 Fibromyalgia:
 Ptns clinically may have poor quality sleep,
structural dysfunction, pain at rest, pain at
function and trigger points.
 Tender points don’t produce heterotopic pain
when palpated (while in trigger point myalgia
does).