TMJ Disc Displacements: Difference between revisions

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# [[Neurological Assessment|Neurological]] signs  
# [[Neurological Assessment|Neurological]] signs  
# Swelling
# Swelling
# Nosebleeding
# Nose bleeding
# Dysphagia or dysarthria
# [[Dysphagia]] or dysarthria
# Unexplained weight loss
# Unexplained weight loss
# Auditory complaints
# Auditory complaints
# Constant pain unrelated to jaw movement
# Constant pain unrelated to jaw movement
Stages of TMJ disc displacement:<ref name=":0">Moffett BC. Definitions of TMJ Derangements. IN: Diagnosis of internal derangements of the TMJ, Vol.1, Double contrast Arthrography and Clinical considerations. BC Moffett and PL Westesson eds. Proceedings of a Continuing Dental Symposium, Seattle 1984.</ref><br>Stage I: Disc displacement with reduction DDWR (hearing and palpating joint noises during opening and closing, protrusive opening and closings stops the reciprocal click)<br>Stage II: Disc displacement without reduction DDWoR (history of clicking and popping with or without intermittent locking, complaint of limited mouth opening)<br>Stage III: Chronic disc displacement without reduction (hearing multiple noises during opening and closing (crepitus), with normal or near normal mandibular dynamics<ref>Eriksson L and Westesson PL. Clinical and radiological study of patients with Anterior disc displacement of the temporomandibular joint. Swed Dent J. 1983; 7:55.</ref>)
 
== Stages of TMJ disc displacement<ref name=":0">Moffett BC. Definitions of TMJ Derangements. IN: Diagnosis of internal derangements of the TMJ, Vol.1, Double contrast Arthrography and Clinical considerations. BC Moffett and PL Westesson eds. Proceedings of a Continuing Dental Symposium, Seattle 1984.</ref> ==
 
=== Stage I ===
Disc displacement with reduction (DDWR):
* Hearing and palpating joint noises during opening and closing
 
* Protrusive opening and closings stops the reciprocal click
 
=== Stage II ===
Disc displacement without reduction (DDWoR)
* History of clicking and popping  
* With or without intermittent locking
* Limited jaw range of movement
 
=== Stage III ===
Chronic disc displacement without reduction
* Hearing multiple noises during opening and closing (crepitus),  
* Normal or near normal mandibular dynamics<ref>Eriksson L and Westesson PL. [https://pubmed.ncbi.nlm.nih.gov/6576492/ Clinical and radiological study of patients with Anterior disc displacement of the temporomandibular joint]. Swed Dent J. 1983; 7:55.</ref>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
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== Management/Intervention  ==
== Management/Intervention  ==


Treatment for disc displacement with reduction (DDwR) without pain: requires no treatment other than:
=== Disc displacement with reduction without pain ===
# Explain to the patient what it is they are experiencing that popping may continue indefinitely, they may experience occasional brief moments of locking.
# Explain to the patient what it is they are experiencing that popping may continue indefinitely, they may experience occasional brief moments of locking.  
# Reassure the patient that what they have is very common, their condition rarely deteriorates to the level of having chronic pain and loss of oral function.  
# Reassure the patient that what they have is very common, their condition rarely deteriorates to the level of having persistent pain and loss of oral function.  
Treatment for DDwR with pain:  
 
# Inform patient that their head, orofacial and neck symptoms may not be related to the DDwR.
=== Disc displacement without reduction<ref>Haketa T, Kino K, Sugisaki M, Takaoka M, Ohta T. [https://journals.sagepub.com/doi/abs/10.1177/0022034510378424 Randomized clinical trial of treatment for TMJ disc displacement.] Journal of dental research. 2010 Nov;89(11):1259-63.</ref> ===
# Physiotherapy and therapeutic exercise
# Splinting
# Joint mobilisation of the TMJ and cervical spine
# TMJ active exercises
# Treat other sources of symptoms that may be unrelated to the DDwR such as: joint inflammation (physical therapy/anti-inflammatory meds), masticatory muscle pain (physical therapy/oral appliance), and referred pain from cervical spine (physical therapy)<ref>Moses JJ, Topper DC. A functional approach to the treatment of temporomandibular joint internal derangement. J Craniomandib Disor Facial &amp; Oral Pain. 1991; 519-27.</ref>
# Treat other sources of symptoms that may be unrelated to the DDwR such as: joint inflammation (physical therapy/anti-inflammatory meds), masticatory muscle pain (physical therapy/oral appliance), and referred pain from cervical spine (physical therapy)<ref>Moses JJ, Topper DC. A functional approach to the treatment of temporomandibular joint internal derangement. J Craniomandib Disor Facial &amp; Oral Pain. 1991; 519-27.</ref>
Treatment of DDwR with locking episodes (patient experiences sudden episodes of limited mouth opening, which returns to normal with spontaneous resolution or resolution in response to force exerted by the patient):  
Treatment of DDwR with locking episodes (patient experiences sudden episodes of limited mouth opening, which returns to normal with spontaneous resolution or resolution in response to force exerted by the patient):  
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== Differential Diagnosis  ==
== Differential Diagnosis  ==
* TMJ differential diagnoses: 
* Pseudo-hypomobilities: muscle spasm, acute surgical, intra and extracapsular irritations, neoplasm, inflammatory diseases, and trauma  
* Pseudo-hypomobilities: muscle spasm, acute surgical, intra and extracapsular irritations, neoplasm, inflammatory diseases, and trauma  
* True hypomobilities: chronic post-surgical, arthritic, fibrosis adhesions  
* True hypomobilities: chronic post-surgical, arthritic, fibrosis adhesions  

Revision as of 10:45, 25 September 2020

Original Editor - Andrea Reineke

Top Contributors - Abbey Wright, Lynda Chukwu, Admin, Kim Jackson, WikiSysop, 127.0.0.1, Andrea Reineke and George Prudden  

Introduction[edit | edit source]

Temperomandibular joint displacement, also known as internal disc derangement, is an abnormal relationship between the articular disc, the mandibular condyle and the mandibular fossa. It is understood that the posterior band of the disc generally lies in front of the condyle and that the condyle functions on the posterior attachment.

Imaging studies have demonstrated that a more anterior disc position are relatively common in the asymptomatic population.[1] It is also thought that in the majority of people the TMJ adapts to the disc position and rarely produces pain from being in a different position. [2]

Clinically Relevant Anatomy[edit | edit source]

See TMJ anatomy

Clinical Presentation[edit | edit source]

Symptoms[3][edit | edit source]

  • Pain or discomfort associated with anyone or combination of: chewing, yawning, talking, bruxism
  • Headaches
  • Ear pain
  • TMJ range of movement may be restricted
  • Crepitus/clicking during movement of the jaw
  • Pain or discomfort can be acute or chronic that can fluctuate in intensity.
  • Emotional issues such as depression is commonly associated with TMJ pain

Duration of symptoms may vary from hours to days.

Red flags[edit | edit source]

  1. Neurological signs
  2. Swelling
  3. Nose bleeding
  4. Dysphagia or dysarthria
  5. Unexplained weight loss
  6. Auditory complaints
  7. Constant pain unrelated to jaw movement

Stages of TMJ disc displacement[4][edit | edit source]

Stage I[edit | edit source]

Disc displacement with reduction (DDWR):

  • Hearing and palpating joint noises during opening and closing
  • Protrusive opening and closings stops the reciprocal click

Stage II[edit | edit source]

Disc displacement without reduction (DDWoR)

  • History of clicking and popping
  • With or without intermittent locking
  • Limited jaw range of movement

Stage III[edit | edit source]

Chronic disc displacement without reduction

  • Hearing multiple noises during opening and closing (crepitus),
  • Normal or near normal mandibular dynamics[5]

Diagnostic Procedures[edit | edit source]

  • Clearing the TMJ could be done with the following imaging: Radiography (normal x-ray and panoramic radiography), Tomogram, Computerized tomography (CT scan), MRI, Arthrography.[6][7][8][9][10]
  • Measurements of maximal mouth opening using a standard ruler have demonstrated an intra-rater reliability of .99 (ICC) and an inter-rater reliability of .94[11]
  • Auscultation During Active Movement: To identify presence of OA on the TMJ. Positive test if crepitus heard by examiner. Sn= .45-.67, Sp= .84-.86, -LR=.38-.65, +LR= 2.8-4.8[12]

Management/Intervention[edit | edit source]

Disc displacement with reduction without pain[edit | edit source]

  1. Explain to the patient what it is they are experiencing that popping may continue indefinitely, they may experience occasional brief moments of locking.
  2. Reassure the patient that what they have is very common, their condition rarely deteriorates to the level of having persistent pain and loss of oral function.

Disc displacement without reduction[13][edit | edit source]

  1. Physiotherapy and therapeutic exercise
  2. Splinting
  3. Joint mobilisation of the TMJ and cervical spine
  4. TMJ active exercises
  5. Treat other sources of symptoms that may be unrelated to the DDwR such as: joint inflammation (physical therapy/anti-inflammatory meds), masticatory muscle pain (physical therapy/oral appliance), and referred pain from cervical spine (physical therapy)[14]

Treatment of DDwR with locking episodes (patient experiences sudden episodes of limited mouth opening, which returns to normal with spontaneous resolution or resolution in response to force exerted by the patient):

  1. Reposition the disc into the condyle
  2. Decrease frequency and duration of locking episodes
  3. Progress DDwR to a functional non-reducing disc.[15]

Since cervical spine disorders coexist 70% of the time with TMD it is very important to screen and treat the cervical spine as necessary[16][17][18]

Differential Diagnosis[edit | edit source]

  • Pseudo-hypomobilities: muscle spasm, acute surgical, intra and extracapsular irritations, neoplasm, inflammatory diseases, and trauma
  • True hypomobilities: chronic post-surgical, arthritic, fibrosis adhesions

References[edit | edit source]

  1. ↑ Kircos LT, Ortendahl DA, Mark AS, Arakawa M. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. Journal of oral and maxillofacial surgery. 1987 Oct 1;45(10):852-4.
  2. ↑ Poluha RL, Canales GD, Costa YM, Grossmann E, Bonjardim LR, Conti PC. Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation. Journal of Applied Oral Science. 2019;27.
  3. ↑ Canales GD, Guarda-Nardini L, Rizzatti-Barbosa CM, Conti PC, Manfredini D. Distribution of depression, somatization and pain-related impairment in patients with chronic temporomandibular disorders. Journal of Applied Oral Science. 2019;27.
  4. ↑ Moffett BC. Definitions of TMJ Derangements. IN: Diagnosis of internal derangements of the TMJ, Vol.1, Double contrast Arthrography and Clinical considerations. BC Moffett and PL Westesson eds. Proceedings of a Continuing Dental Symposium, Seattle 1984.
  5. ↑ Eriksson L and Westesson PL. Clinical and radiological study of patients with Anterior disc displacement of the temporomandibular joint. Swed Dent J. 1983; 7:55.
  6. ↑ Kraus S. (1994). Clinics in Physical Therapy: Temporomandibular Disorders (2nd edition). Churchill Livingstone: New York.
  7. ↑ Helms CA, Kaplan R. Diagnostic imaging of the temporomandibular joint: recommendations for use of the various techniques. AM J Roentgenol. 1990: 154;319.
  8. ↑ Pharoah M. The prescription of diagnostic images for temporomandibular joint disorders. J of Orofascial Pain. 1999; 13(4): 251-254.
  9. ↑ Trumpy I, Erickson J, Lyberg T. Internal derangement of the temporomandibular joint: Correlation of arthrographic imaging with surgical findings. Int J Oral Maxillofac Surg. 1997; 26:327-330.
  10. ↑ Watt-Smith S, Sadler A, Baddeley H, et al. Comparison of arthrotomographic and magnetic resonance images of 50 temporomandibular joints with operative finds. Br J Oral Maxillofac Surg. 1993; 31:139-143.
  11. ↑ Walker N, Bohannon RW, Cameron D. Discriminant validity of temporomandibular joint range of motion measurements obtained with a ruler. J Orthop Sports Phys Ther. 2000 August;30(8): 484-92.
  12. ↑ Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for an Evidence-based Clinician. EIM. 2008:180.
  13. ↑ Haketa T, Kino K, Sugisaki M, Takaoka M, Ohta T. Randomized clinical trial of treatment for TMJ disc displacement. Journal of dental research. 2010 Nov;89(11):1259-63.
  14. ↑ Moses JJ, Topper DC. A functional approach to the treatment of temporomandibular joint internal derangement. J Craniomandib Disor Facial & Oral Pain. 1991; 519-27.
  15. ↑ Yoda T, Sakamoto I, Imai H, et al. Response of temporomandibular joint intermittent closed lock to different treatment modalities: A multicenter Survey. J Craniomadndib Practice. 2006; 24(2): 130-6.
  16. ↑ Ciancaglini R, Testa M, Radaelli G. Association of neck pain with symptoms of TMD in the general adult population. Scand J Rehab Med. 1999; 31:17-22.
  17. ↑ Sjaastad O, Saunte C, Hovdal H, et al. “Cervicogenic” headache. An hypothesis. Cephalalgia. 1983; 3:249-256.
  18. ↑ Kuttila S, Kuttila M, Le Bell Y, et al. Characteristics of subjects with secondary otalgia. Journal of Orofacial Pain. 2004; 18(3):226-234.
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