TMJ Disc Displacements: Difference between revisions

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== Introduction  ==
== Introduction  ==


[[TMJ Anatomy|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.  
[[TMJ Anatomy|Temperomandibular joint]] displacement, also known as internal disc derangement, is an abnormal relationship between the articular disc, the mandibular condyle and the mandibular fossa<ref>Young AL. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762294/ Internal derangements of the temporomandibular joint: A review of the anatomy, diagnosis, and management.] The Journal of the Indian Prosthodontic Society. 2015 Jan;15(1):2.</ref>. 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.<ref>Kircos LT, Ortendahl DA, Mark AS, Arakawa M. [https://pubmed.ncbi.nlm.nih.gov/3477621/ Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers]. Journal of oral and maxillofacial surgery. 1987 Oct 1;45(10):852-4.</ref> 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. <ref>Poluha RL, Canales GD, Costa YM, Grossmann E, Bonjardim LR, Conti PC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382319/ Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation.] Journal of Applied Oral Science. 2019;27.</ref>   
Imaging studies have demonstrated that a more anterior disc position are relatively common in the asymptomatic population.<ref>Kircos LT, Ortendahl DA, Mark AS, Arakawa M. [https://pubmed.ncbi.nlm.nih.gov/3477621/ Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers]. Journal of oral and maxillofacial surgery. 1987 Oct 1;45(10):852-4.</ref> 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. <ref>Poluha RL, Canales GD, Costa YM, Grossmann E, Bonjardim LR, Conti PC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382319/ Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation.] Journal of Applied Oral Science. 2019;27.</ref>   
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# Constant pain unrelated to jaw movement
# Constant pain unrelated to jaw movement


== Stages of TMJ disc displacement ==
== Types of TMJ disc displacement ==
 
# Disc displacement with reduction (DDWR):  
=== Stage I ===
Disc displacement with reduction (DDWR):  
* Hearing and palpating joint noises during opening and closing
* Hearing and palpating joint noises during opening and closing


* Protrusive opening and closings stops the reciprocal click
* Protrusive opening and closings stops the reciprocal click
 
2. Disc displacement without reduction (DDwoR)<ref name=":1">Al-Baghdadi M, Durham J, Araujo-Soares V, Robalino S, Errington L, Steele J. [https://journals.sagepub.com/doi/full/10.1177/0022034514528333# TMJ disc displacement without reduction management: a systematic review.] Journal of dental research. 2014 Jul;93(7_suppl):37S-51S.</ref>  
=== Stage II ===
Disc displacement without reduction (DDwoR)<ref name=":1">Al-Baghdadi M, Durham J, Araujo-Soares V, Robalino S, Errington L, Steele J. [https://journals.sagepub.com/doi/full/10.1177/0022034514528333# TMJ disc displacement without reduction management: a systematic review.] Journal of dental research. 2014 Jul;93(7_suppl):37S-51S.</ref>  
* TMJ pain  
* TMJ pain  
* Limited jaw range of movement  
* Limited jaw range of movement  
* Clicking and popping  
* Clicking and popping  
* With or without intermittent locking
* With or without intermittent locking
=== 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>


These stages are under review and a new classification system is being trialled however at present it has only been trialled in adolescents.<ref name=":0">Shen P, Xie Q, Ma Z, Abdelrehem A, Zhang S, Yang C. [https://www.nature.com/articles/s41598-019-42081-5 Yang’s Classification of Juvenile TMJ Anterior Disc Displacement Contributing to Treatment protocols]. Scientific reports. 2019 Apr 4;9(1):1-8.</ref> This classification reports five stages of disc displacement based on MRI results.  
These stages are under review and a new classification system is being trialled however at present it has only been trialled in adolescents.<ref name=":0">Shen P, Xie Q, Ma Z, Abdelrehem A, Zhang S, Yang C. [https://www.nature.com/articles/s41598-019-42081-5 Yang’s Classification of Juvenile TMJ Anterior Disc Displacement Contributing to Treatment protocols]. Scientific reports. 2019 Apr 4;9(1):1-8.</ref> This classification reports five stages of disc displacement based on MRI results.  

Revision as of 11:53, 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[1]. 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.[2] 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. [3]

Clinically Relevant Anatomy[edit | edit source]

See TMJ anatomy

Clinical Presentation[edit | edit source]

Symptoms[4][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

Types of TMJ disc displacement[edit | edit source]

  1. Disc displacement with reduction (DDWR):
  • Hearing and palpating joint noises during opening and closing
  • Protrusive opening and closings stops the reciprocal click

2. Disc displacement without reduction (DDwoR)[5]

  • TMJ pain
  • Limited jaw range of movement
  • Clicking and popping
  • With or without intermittent locking

These stages are under review and a new classification system is being trialled however at present it has only been trialled in adolescents.[6] This classification reports five stages of disc displacement based on MRI results.

Yang’s Classification of Juvenile TMJ Anterior Disc Displacement:[6][edit | edit source]

stage Disc Condyle Marrow
Stage 0 Basic shape Normal condylar shape and height Normal volume and quality
Stage 1 Basic shape Mild and local condylar resorption, but normal condylar height Partially reduced on the top
Stage 2 Basic shape Moderate condylar resorption, reduced condylar height. Mildly reduced
Stage 3 Basic shape or distorted Severe condylar resorption Moderately reduced
3A Basic shape remains, or mildly distorted and shortened Small, but basic shape is present Moderately reduced
3B Severely distorted and shortened Small, but basic shape is present Moderately reduced
Stage 4 Basic shape or distorted Severe condylar resorption Moderately reduced with inflammatory changes, or severe reduced, or absent
4A Basic shape remains or distorted. Perforation is common Severe resorption, loss of integrity of cortical bone. Moderately reduced with severe inflammatory changes
4B Basic shape remains or distorted. Perforation is common Severe resorption, or complete resorption Severe reduced, or absent

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.[7][8][9][10][11]
  • 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[12]
  • 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[13]

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[14][edit | edit source]

The best treatment plan for disc displacement without reduction is still under discussion and requires more evidence as treatment is usually based on experience rather than evidence.[5]

Interventions can range from conservative management to surgical intervention. Although primary management for disc displacement should always be conservative.[15]

Conservative management (primarily physiotherapy)[5][edit | edit source]

  1. Education and self-management
  2. Splinting
  3. Therapeutic exercise
  4. Joint mobilisation of the TMJ and cervical spine
  5. Active jaw exercises and strengthening
  6. Cognitive behavioural therapy
  7. NSAIDs and analgesia

Surgical intervention[edit | edit source]

  1. Arthrcentesis
  2. Arthroscopy
  3. Open joint intervenetion

On analysis of the surgical interventions there was no change in outcomes (pain and TMJ range of movement) when compared with each other. [5]

Clinical bottom line[edit | edit source]

Regardless of intervention disc displacement without reduction has shown to improve over time, therefore the optimum treatment would be the least invasive and most cost effective i.e. education, self-management and early TMJ manipulation.[5] In some extreme cases surgical intervention may be required but should be treated as a last choice.

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.[16]

Since cervical spine disorders coexist 70% of the time with TMD it is very important to screen and treat the cervical spine as necessary[17][18][19]

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. ↑ Young AL. Internal derangements of the temporomandibular joint: A review of the anatomy, diagnosis, and management. The Journal of the Indian Prosthodontic Society. 2015 Jan;15(1):2.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Al-Baghdadi M, Durham J, Araujo-Soares V, Robalino S, Errington L, Steele J. TMJ disc displacement without reduction management: a systematic review. Journal of dental research. 2014 Jul;93(7_suppl):37S-51S.
  6. ↑ 6.0 6.1 Shen P, Xie Q, Ma Z, Abdelrehem A, Zhang S, Yang C. Yang’s Classification of Juvenile TMJ Anterior Disc Displacement Contributing to Treatment protocols. Scientific reports. 2019 Apr 4;9(1):1-8.
  7. ↑ Kraus S. (1994). Clinics in Physical Therapy: Temporomandibular Disorders (2nd edition). Churchill Livingstone: New York.
  8. ↑ Helms CA, Kaplan R. Diagnostic imaging of the temporomandibular joint: recommendations for use of the various techniques. AM J Roentgenol. 1990: 154;319.
  9. ↑ Pharoah M. The prescription of diagnostic images for temporomandibular joint disorders. J of Orofascial Pain. 1999; 13(4): 251-254.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for an Evidence-based Clinician. EIM. 2008:180.
  14. ↑ 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.
  15. ↑ Schiffman EL, Look JO, Hodges JS, Swift JQ, Decker KL, Hathaway KM, Templeton RB, Fricton JR. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. Journal of dental research. 2007 Jan;86(1):58-63.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ Sjaastad O, Saunte C, Hovdal H, et al. “Cervicogenic” headache. An hypothesis. Cephalalgia. 1983; 3:249-256.
  19. ↑ 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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