Management of Temporomandibular Joint Pain and Dysfunction

Management of Temporomandibular Joint Pain and Dysfunction

Joseph J. Fantuzzo

Sveta Karelsky

Temporomandibular disorders (TMDs) are conditions affecting or arising from the temporomandibular joint (TMJ), muscles of mastication, or both. TMD typically manifests as pain in the head and neck region and there is often an effect on neighboring structures. The pain can mimic other painful disorders of the head and neck as well. TMDs may be interpreted as facial pain, headaches, earaches, aural fullness, clicking or popping of the ears, mild hearing loss, tinnitus, dizziness, difficulty with mouth opening, chewing or speech, closed or open lock of the TMJ, wear of the occlusal (biting) surfaces of the teeth, joint noises (clicking or popping), and other complaints. TMDs occur in an estimated 5% to 15% of the general population, peaking in young adults age 20 to 40 years. Signs of TMD occur equally in males and females, but symptoms occur and are reported more frequently in women of childbearing age. Approximately 2% of the general population seeks treatment for TMJ-related symptoms (1,2).

Patients with complaints of TMJ-related pain often have parafunctional oral habits or a history of trauma, as well as concomitant medical or psychological conditions. TMJ disorders TMDs may be divided into nonarticular muscle disorders and articular (intracapsular) disorders. Nonarticular disorders include masticatory muscle (myofascial) pain and dysfunction and can commonly be associated with fibromyalgia or other chronic pain states and irritable bowel syndrome (3). Trauma can affect the TMJ itself and associated structures. Articular disorders include osteoarthrosis, inflammatory joint diseases, infections, and benign and malignant lesions.

The role of the otolaryngologist is both to differentiate temporomandibular from other regional pathology and to initiate a treatment plan for the disease. Because of the variety of symptomatic presentations of TMDs patient perceptions of the origin of symptoms vary widely. Patients may be referred to the otolaryngologist for presumed pathology of the ear, sinuses, or parotid gland. It is not uncommon for patients to have been treated for infectious disorders of these structures prior to referral. An appropriate explanation of the anatomic basis of pain must be provided for the patient if trust is to be gained and recommendations are to be carried out. Symptoms and their severity must be accepted as reported and treated accordingly. Accurate diagnosis is important in the development of an effective treatment plan.

Patients should be reassured that TMD is generally a benign condition and clinical improvement is expected in time and with appropriate therapy. Complete elimination of symptoms is difficult and at times impossible. The goals of therapy include patient education, alleviation of pain, and improvement in jaw function.

Pain and jaw dysfunction are the hallmarks of TMD, and the pathophysiology, differential diagnosis, and management of the problems behind pain and limited jaw function are the primary focus of this chapter.


The TMJ exists between the base of the skull (temporal bone) and the mandible (condylar process). The articulating bony surfaces, the articular disk, several ligaments, and numerous associated muscles make up the joint (Fig. 54.1). The purpose of the temporomandibular (or craniomandibular) articulation is to provide range of motion and to allow for the functional aspects of the mouth and jaws during breathing, speech articulation, mastication, and swallowing.

Of the bones of the head, only the TMJ and the ossicles of the ear have articulations. The secondary TMJ in humans develops by the 10th week of gestation, from mesenchymal condensations of two separate blastemas for the condyle and temporal bone. The TMJ and ear ossicles are derived from membranous bone (4,5). Superior to the condylar blastema, a band of mesenchymal tissue differentiates into
the disc as an extension of the lateral pterygoid muscle (4,5,6). Embryologic studies suggest an intimate relationship between the fetal TMJ and the middle ear through the petrotympanic fissure. This relationship may contribute to referred pain patterns or the spread of infection (7).

Figure 54.1 TMJā€”Normal anatomy.

The articular disc is a biconcave structure that prevents bone on bone contact of the articulating surfaces and more evenly distributes articular forces. It has an anterior and posterior band and intermediate, thinner avascular zone. The disc is also attached at the medial and lateral condylar poles. The disc divides the articular space of the TMJ into a superior and inferior joint space. Posteriorly, the retrodiscal attachment is bilaminar and has significant neurovascularity. This retrodiscal tissue is intracapsular, and pain within the joint itself may be due to retrodiscal injury or inflammation. Theories of intracapsular pain are discussed later in the chapter (4,5).

The development of the primary and adult dentition influences the shape of the fossa, eminence, and condylar head. The glenoid fossa represents a concavity within the temporal bone that fits the mandibular condyle. The anterior wall of the fossa is the articular eminence. The posterior wall, made up of the tympanic plate of the temporal bone, is also the anterior wall of the external acoustic meatus. An early periosteal lining becomes the dense, avascular, fibrous connective tissue cover for the articular surfaces. The articulating surfaces are different from hyaline cartilage surfaces of other synovial joints. Edentulism leads to secondary change within the fossa and eminence (8).

The TMJ is thinly encapsulated anteriorly, medially, and posteriorly, with a thick capsule laterally forming the temporomandibular ligament. The ligament has a narrow deep portion and wider fan-shaped lateral portion. The fibrous capsule and ligament provide support and limit jaw range of motion.

The sensory innervation of the TMJ is from the auriculotemporal, deep temporal, and masseteric nerves. The blood supply to the capsule and disc is from the branches of the maxillary artery.

The motor activity of the joint results from motor innervation of the masticatory musculature, through the third division of the trigeminal nerve. The various muscle groups of the face, tongue, palate, and hyoid are also involved in functions that include the TMJ: The masticatory muscles (masseter, temporalis, medial pterygoid, and lateral pterygoid) and other important muscles (digastrics and supra-and infrahyoid muscle groups) play a significant role in the functioning of the TMJ. The actions of the muscles together on the hyoid, mandible, and related structures are important during jaw function. This interrelationship is important to consider when arriving at a differential diagnosis. A thorough review of anatomy including the actions of this musculature is beyond the scope of this chapter.

Movements of the mandible include opening and closing, protrusion, retrusion, and lateral excursions. The motion of the mandible at the TMJ is hinge-like occurring primarily within the lower compartment and gliding or translatory within the upper compartment. Unlike other joints, the left and the right side disc, condyle, and associated musculature function simultaneously. Maximum mandibular opening (between incisors) is 40 to 55 mm, is generally less in women, and decreases with advancing age (4,5,9).

May 24, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Management of Temporomandibular Joint Pain and Dysfunction

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