International Research Journal of Engineering and Technology (IRJET) e-ISSN: 2395-0056
Volume: 09 Issue: 08 | Aug 2022 www.irjet.net p-ISSN: 2395-0072
Internal Derangement of Temporomandibular Joint-A review of Anatomy, Clinical manifestations, Diagnosis and Management.
1BDS Final year student,Vananchal Dental College and Hospital,Garhwa,Jharkhand,India 2 Senior lecturer,Vananchal Dental College and Hospital,Garhwa,Jharkhand,India 3 Lecturer Vananchal Dental College and Hospital,Garhwa,Jharkhand,India
4Private practitioner,Jharkhand,India ***
Abstract - Internal derangement of temporomandibular joint is referred to as a pathologic entity . It represents displacement of an articular disc from its normal anatomic position . This article includes a brief description of the anatomyofTMJ, variousclinicalpresentationsassociatedwith anterior disc displacement. Appropriate management ranges from conservative care & non surgical therapy to surgical interventions, are described also.
Key Words: Internal derangement, disc displacement, temporomandibular disorders, joint noises, disc displacement with reduction and without reduction.
1.INTRODUCTION
Temporomandibular disorders (TMDs) means problems related with temporomandibular joint, muscles of mastication&associatedstructuresalso. TMDsrepresent oro-facial pain, limitation in mandibular movement, pain during mandibular function. It also includes various joint soundslikecatching,clicking,popping,snappingetc[3,5]
1 ANATOMY OF TEMPOROMANDIBULAR JOINT:
● TMJisacompoundjoint,composedof4articulating surfaces- 1) glenoid fossa of temporal bone, 2) mandibular condyle,3) superior & 4) inferior surfaceofarticulardisc.[1]
● TMJ is also a synovial joint because synovial membrane lines the inner aspect of the joint . It secretes synovial fluid which lubricates the joint duringmovement.Italsoprovidesnutritiontothe asvascularjoint.[1]
● Articulardisc isa fibrocartilaginous band present between condyle and articular eminence of temporalbone.[1] Itisabiconcaveellipticalshaped disc.Itisthinatthecentreandtheposteriorborder isthickerascomparedtotheanteriorborder.[1,5]It divides the joint cavity in two parts- 1) superior joint cavity and 2) inferior joint cavity. It adapts itselfaccordingtothejointmovement,becauseof itsflexibility.[1,2,4]
● TMJ is also called- ginglymoarthrodial joint. The inferior joint cavity allows hinge or rotational movement, hence called ‘ginglymoid’. And the superiorcavityallowsslidingmovement,sothatit’s calledan‘arthrodialjoint’.[1,2,3]
● Mandibular fossa or glenoid fossa is a concave depressionoftemporalbone.Itispresentbetween posterior slope of articular eminence and post glenoidtubercle.Theboneinthecenterofarticular fossa is very thin, hence it is not a major stress bearingareaforTMJ.[1]
● Thearticulareminenceisasmallprojectiononthe zygomaticarch.Itprovidesattachmentforcollateral ligaments. It has 3 parts- descending slope, a transverseridgeandanascendingslope.[3]
● Mandibular condyle is of elliptical shape.[3] It providesattachmentforcollateralligaments.Onthe medial aspect of condyle, there’s a depression called-pterygoidfovea.Itprovidesattachmentfor lateralpterygoidmuscle.[1]
● Bothtemporalboneandcondylearecoveredwith thick,avascularfibro-cartilage.Itisdifferentfrom otherjointsbecausetheyarecoveredwithhyaline cartilage.[2]
● Fibrocartilageshowslessdamageovertimeandhas capacitytorepairandregenerate.Itiscomposedof fibro-chondrocytes, fibroblast-like cells, type I collagenfibersandproteoglycans.[1,2]
● TheTMJiscoveredwithhighlyvascularfibroelastic connective tissue capsules.[2] The inner surface of thecapsuleislinedwithasynovialmembrane.It’sa vascularised,thin,smoothtissuewithoutepithelium . It has the capacity to regenerate after an injury. Synovialfluidresemblesanultrafiltrateof plasma. Ithelpsinlubricationofjointsandreducesfriction during joint movement, nourishes the joint & phagocytose the debris. The volume of synovial fluidintheuppercompartmentisabout1.2mLand in the lower compartment it’s about 0.9 ml. It
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International Research Journal of Engineering and Technology (IRJET) e-ISSN: 2395-0056
Volume: 09 Issue: 08 | Aug 2022 www.irjet.net p-ISSN: 2395-0072
consistsofmorealbuminthanglobulin,hyaluronic acid,PMNs&lubricin.[1,3]
● Retrodiscal tissue is a bilaminal structure. It is highly vascular and innervated. Articular disc blends with it posterioly. Superior retrodiscal laminaismadeupofelasticfibersandisattached with a tympanic plate. It limits the excessive translators movement of condyle. The inferior laminaismadeupofcollagenfibers.Itisconnected withanarticulardisconthearticularsurfaceofthe condyle. It may prevent extreme rotational movementofcondyle.[1,2]
● There are 3 functional ligaments and 2 accessory ligaments are associated with TMJ. 3 functional ligaments are- 1) collateral ligament, 2)capsular ligament, 3) temporomandibular ligament. Accessory ligaments are- sphenomandibular ligamentandstylomandibularligament.[4]
2. INTERNAL DERANGEMENT OF TMJ
Accordingtothediagnosticcriteriafortemporomandibular disorders proposed by DC/TMD, various types of internal derangement of TMJ are described briefly. It is an easier adaptation from Schiffman et al.- diagnostic criteria for temporomandibular disorders (DC/ TMD) for clinical and researchapplication.[5,6,15]
2.1 Disc displacement with reduction: It represents a conditioninwhichthediscisplacedanteriortothe condyleinclosed mouthposition. Whena patient opens the mouth ,the disc reduction occurs. Reduction means to assume a normal position in relation to the condyle and glenoid fossa. On opening the mouth, condyle passes over the posteriorareaofthedisc&aclickingsoundoccurs. Clicks are reciprocal as it occurs during mouth openingandduringclosing.Therangeofmotionis not limited because of disc reduction . This condition is usually unilateral. Pain is usually not present.[1,6]
2.2 Discdisplacementwithreductionwithintermittent locking:Thecondyleisanteriortothediscinclosed mouthposition,butitdoesn’talwaysreducetoits normalposition.HenceintermittentlockingofTMJ occurs. It will limit the mandibular movement intermittently.Patientneedstonegotiatetounlock the TMJ. Joint noises like clicking,popping or snapping sounds occur during reduction of the disc.[6]
2.3 Disc displacement withoutreductionwithlimited opening:Inclosedmouthposition,discisanterior to the condylar head but the disc is not reduced back to its normal position while opening the
mouth.Itrepresentspersistentlimitedmandibular opening instead of manipulation done by the patient. Hence it’s called a ‘ closed lock’. Limited openingofmouthmakesthepatientunabletoeat. Maximumopeningwithoverbiteisabout<40mm. Overstretching of highly vascular & innervated retrodiscal tissue cause pain while forceful opening.[1,6]
2.4 Disc displacement without reduction without limitedopening:Thediscisanteriortothecondyle inclosedmouthpositionanddiscisnotreducedto its original position on opening the mouth . Maximum mouth opening with vertical incisal overlapisabout>40mm.Patientisunabletoeat.[6]
2.5 Anchored disc phenomenon: It’s also called acute disc displacement. It represents sudden ,severe persistent limited mouth opening, without reduction.Maximummouthopeningisabout10-30 mm.Patientexperiencespainwhileforcedmouth opening.[1]
3. CLINICAL FEATURES AND DIAGNOSIS
● Internal derangement of TMJ is considered as a progressivedisorder.Thesignsandsymptomsare collectively called TMJ syndrome. They includepain,jointnoiselikeclickingorpopping,reduction inmouthopening.Painissignificantincaseofdisc displacementwithoutreduction.[6,8] Theremaybe secondarychangeslikeretrodiscitisandcapsulitis. As condyle is functioning on retrodiscal tissue instead of disc, there may be a chance of retrodiscitis. Internal derangement can be unilateralorbilateral.Unilateralcasesmanifestas deviationofthemandibleontheaffectedside.[1,2,6]
● Patient history and examination are utmost important to diagnose the disorder. It should include- examination of TMJ & muscle of mastication , maximal mouth opening, occlusion, presenceofpara-functionalhabitetc.[2,8]
● Theearlystagei.ediscdisplacementwithreduction is characterized by clicking. Joint noises may be audibleorpalpable.Clickingoccurswhileopening the mouth as well as while closing mouth. If the opening click is too early, it suggests minimal anterior disc displacement. If the click is too late, moredisplacementhasoccurred.Whendiscisnon reducible, there’s no contact between articulating surfaces of condyle and disc. Hence clicking will disappearorreduceitsintensity.[8]
● The clinician must evaluate the muscles of mastication.Ifthere’sanypainonpalpation,trigger
2022, IRJET | Impact Factor value: 7.529 | ISO 9001:2008 Certified Journal |
International Research Journal of Engineering and Technology (IRJET) e-ISSN: 2395-0056
Volume: 09 Issue: 08 | Aug 2022 www.irjet.net p-ISSN: 2395-0072
points, localized tenderness , those will indicate myalgia.[2]
● Radiographicevaluation:Conventionalradiography & tomography cannot evaluate the disc. Arthrography&MRIarethetechniquesofchoice MRI can assess the condyle, fossa, eminence , the disc and its position ,shape, density, size, perforation etc. MRI compares the images of disc and condyle in closed mouth and open mouth position & differentiate between the disc displacement with reduction from the disc displacementwithoutreduction.[1,2,7]
4 .MANAGEMENT
● Thegoalsforthetreatmentofinternalderangement are- 1) to reduce patient discomfort, 2) to reduce pain, 3) to increase the mouth opening, 4) to eliminatethejointnoisesetc.[2]
4.1 Non surgical management
● Discdisplacementwithreduction:Itdoesn’trequire any major treatment if disc displacement is not accompanied with pain. Sudden click, loud joint noise,instability ofthejoint,manipulation during closing the mouth, these things make the patient anxiousandfearful.Insuchcases,patienteducation isverymuchneeded.Theclinicianshouldexplain thereasonsbehindthistothepatientinveryeasy languageandnotreatmentisrequired.[2,9]
● Ifa patientcomplainsofpainful clicking,thenflat planestabilizationtherapy&anteriorrepositioning splint can be used. Anterior repositioning splint maintains the mandible in anterior position. The clinicianguidesthemandibleinforwarddirection, reducingthedisc&replicatingthispositioninthe appliance.Butitisnotsoeffective.Symptomsmay resolvebutthediscremainsdisplaced.Itisadvised toweartheapplianceforfulltime&thenuseitfor nighttimeonly.Thisappliancecancauseposterior openbite&irreversibleocclusalchanges.Hencefull timewearingisn’trecommendedsometimes.[8,9]
● Ifpain&inflammationisthere,NSAIDsareeffective to reduce the pain and inflammation. Muscle relaxants,tricyclics,sedativesarealsogiven.[2,9]
● Discdisplacementwithreductionwithintermittent locking:Iflockingoccursrarely,thenmanagement is the same as disc displacement with reduction without intermittent locking. If locking occurs frequently ,then it is advised to perform certain mobilization movements like open, protrusive, retrusive, laterotrusive etc. Patients should
performtheseexerciseswithoutallowingthediscto re-displace.[5]
● Disc displacement withoutreductionwithlimited opening:Treatmentdependsonthedegreeofpain &limitationofjointmovementassociatedwithdisc displacement. Patients with restricted mouth opening with pain, can be benefitted by manual manipulation and flat plane occlusal stabilization with NSAIDs. This reduces the pain and inflammation & also increases range of motion. It alsoreducesmuscleactivityandheadachesrelated tosleepbruxismorclenching.Manualmanipulation canbeperformedbyholdingthemandibularmolars with thumbs bimanually. The affected side is pressed inferiorly and then brought anteriorly to seatthecondyleonthedisc.[5,9]
4.2 Surgical procedure:
● Arthrocentesis: Patients with severe pain on mandibular movement, can be benefitted by arthrocentesisorarthroscopy.Arthrocentesisisa minimallyinvasiveprocedure.Itprovideslysisand lavageoftheupperjointspace.[2] Firstbupivacaine orarticainewith1:100000adrenalineisinjectedto anaesthetize the auriculotemporal nerve.[14] This procedureusestwoneedles-oneinflowneedleand oneoutflowneedle.Firsttwopointsaremarked.1st point is marked at 10 mm from mid tragus and 2 mm below cantho-tragal line. The 2nd point is marked 10 mm from the first point. Using a 19 gauge needle, 2-4 ml Ringer Lactate solution is injected at the first point to fill the joint space. Another needle is injected at the second point to establishoutflowofthesolution.Atleast300-400 ml solution is used in this procure. This high pressure irrigation or lavage washes away inflammatorymediators,debris,cytokines,matrix metalloproteinase, eliminates intra articular adhesions and provides pain relief & improves rangeofmotioninimmediatepostoperativeperiods . Several studies reported that success rate in treatinginternalderangementis70-95%.[2,5,14]
● Arthroscopy:Itisamoreaggressiveprocedurewith successrate78-90%approximately.Thisprocedure usesastandardoperativearthroscopeandcannula tolyseadhesions.[2,5]
● Arthroplasty:It’sanopenjointsurgicalprocedure. In this technique, the attachments of the disc are released&allowpassivemovementofthedisc.This technique has several adverse effects includingswellingoftheTMJregion,numbness,facialnerve injuryetc.Thisproceduremarkedlyimprovesthe rangeofmotion,reducesthepain&jointnoises.[2,5]
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5. CONCLUSION:
Now a days, internal derangement is not so uncommon. Mostofthepatientsadaptwithminimalproblemsoverthe time.Conservativecare,useofNSAIDs,musclerelaxant,can benefitthepatientinmostofthecases. Patienteducation should include- soft diet, awareness regarding parafunctional habitslikeclenching&sleepbruxism,useofnight guard,hotandcoldpack etc.Postural training,massageor muscleconditioning,mobilizationexercisescanbebeneficial forthepatient.Surgicalinterventionisrarelyneeded.
6. AKNOWLEDGEMENT: Dr.Nikhil Kumar Dwivedi
7. REFERENCES:
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