4/17/26 1 INTRACAPSULAR DISORDERS OF THE TMJ Pathophysiology, Diagnosis & Management Dr Supeetha Suntharamoorthy Oral Medicine Specialist Devaraj SD, Pradeep D. 2014. Internal Derangement of Temporomandibular Joint - A Review. IOSR Journal of Dental and Medical Sciences, 13, 66-73. Available from: http://www.iosrjournals.org/iosr- jdms/papers/Vol13-issue3/Version-2/S013326673.pdf 1 LEARNING OBJECTIVES Understand intracapsular TMJ disorders Recognise clinical features Apply diagnostic frameworks Develop management plans Reading resources: 1. Farah CS, Balasubramaniam R, McCullough MJ. 2019. Contemporary Oral Medicine. Springer Nature Switzerland. Available from: https://doi.org/10.1007/978-3-319-72303-7 2. Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri. 3. Schiffman et al. 2014. The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). J Oral & Facial Pain & Headache. Available from: https://inform-iadr.com/index.php/tmd-assessmentdiagnosis/dc-tmd/ 2   #### Pathophysiology, Diagnosis & Management Presented by Dr. Supeetha Suntharamoorthy, Oral Medicine Specialist. **Reference:** - Devaraj SD, Pradeep D. 2014. Internal Derangement of Temporomandibular Joint - A Review. IOSR Journal of Dental and Medical Sciences, 13, 66-73. #### Core Competencies - Understand intracapsular TMJ disorders - Recognise clinical features - Apply diagnostic frameworks - Develop management plans #### Recommended Reading Resources 1. Farah CS, Balasubramaniam R, McCullough MJ. 2019. Contemporary Oral Medicine. Springer Nature Switzerland. 2. Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri. 3. Schiffman et al. 2014. The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). J Oral & Facial Pain & Headache. Anatomical diagram of the temporomandibular joint (TMJ) showing key structures including the glenoid fossa, articular eminence, coronoid process, mandibular notch, ramus, condyle, bilaminar zone, and TMJ disc. A red arrow points to the TMJ disc, highlighting its position between the condyle and articular eminence. Illustration of the temporalis muscle with labels for the inferior head portion (IHP) and origin portion (OOP), demonstrating anatomical divisions relevant to intracapsular TMJ disorders. 4/17/26 ### KEY TMJ ANATOMY ```mermaid graph TD A[Mandibular condyle] --> B[Mandibular/Glenoid fossa temporal bone] A --> C[Articular/TMJ disc] C --> D[Bilaminar zone <br> • Superior retrodiscal lamina <br> • Inferior retrodiscal lamina <br> • Retrodiscal tissue] C --> E[Capsular ligaments] E --> F[Synovial membrane and joint fluid] ``` 3 ### KEY TMJ ANATOMY **CONDYLE** **MANDIBULAR/GLENOID FOSSA** **Fig. 1.11.** The Condyle. **A,** Anterior and, **B,** posterior views. A dotted line marks the border of the articular surface. Note that the articular surface on the posterior aspect of the condyle is greater than on the anterior aspect. **Fig. 1.12. A.** Bony structures of the temporomandibular joint (lateral view). **B.** Articular fossa (in view). *AE*, Articular eminence; *MF*, mandibular fossa; *STF*, squamotympanic fissure. Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri. 4   #### Anatomical Components - Mandibular condyle - Mandibular/Glenoid fossa of the temporal bone - Articular/TMJ disc - Bilaminar zone - Superior retrodiscal lamina - Inferior retrodiscal lamina - Retrodiscal tissue - Capsular ligaments - Synovial membrane and joint fluid #### Condyle Characteristics - The articular surface on the posterior aspect of the condyle is greater than on the anterior aspect. #### Bony Structures of the Fossa - Articular eminence (AE) - Mandibular fossa (MF) - Squamotympanic fissure (STF) Composite educational slide titled 'KEY TMJ ANATOMY'. The left side contains a structured flowchart with colored boxes outlining the components of the temporomandibular joint: Mandibular condyle, Mandibular/Glenoid fossa, Articular/TMJ disc (with sub-components like Bilaminar zone), Capsular ligaments, and Synovial membrane. The right side features a detailed anatomical line drawing labeled 'Lateral view' of the TMJ, identifying structures such as the Condyle, Ramus, Mandibular notch, Coronal process, Lateral pterygoid muscle, Articular eminence, Glenoid fossa, TMJ capsule, TMJ disc, Retrodiscal tissue, and Bilaminar zone. A composite figure illustrating key TMJ anatomy containing clinical photographs. Top-left panel (Fig. 1.11) shows anterior and posterior views of the mandibular condyle, highlighting the articular surface border with a dotted line. Bottom-left panel (Fig. 1.12 A) displays bony structures of the TMJ lateral view, labeling the Articular Eminence (AE) and Mandibular Fossa (MF). Right panel (Fig. 1.12 B) shows the Articular Fossa with arrows pointing to AE, MF, and Squamotympanic fissure (STF). <date>4/17/26</date> <slide number>5</slide> ## KEY TMJ ANATOMY ### ARTICULAR DISC Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri. * Biconcave structure * Dense fibrous CT, avascular, aneural * Flexible and adaptive * Morphology affected by destructive forces * 3 zones: Anterior (AB), Intermediate (IB), Posterior (PB) <slide number>6</slide> ## KEY TMJ ANATOMY ### BILAMINAR ZONE ### RETRODISCAL TISSUES Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri.    #### Articular Disc Properties - Biconcave structure - Dense fibrous connective tissue - Avascular and aneural - Flexible and adaptive - Morphology is affected by destructive forces #### Disc Zones 1. Anterior (AB) 2. Intermediate (IB) 3. Posterior (PB) #### Retrodiscal Tissues - Includes the bilaminar zone consisting of superior and inferior laminae. Labelled diagram of the Temporomandibular Joint (Fig. 1.13). The image displays two views: 'A Sagittal view' showing the relationship between the condyle and articular disc zones (PB, IZ, AB), and 'B Anterior view' showing a specimen with labels for Disc, LP (Lateral pole), and MP (Medial pole). Labelled anatomical illustration of the Temporomandibular Joint (Fig. 1.15). View B shows a detailed sagittal section with callouts for SRL, SC, AS, ACL, IC, RT, IRL, SLP, and ILP. A green box highlights the bilaminar zone. Clinical photograph labeled 'A' showing the Bilaminar Zone and Retrodiscal Tissues. It features close-up views of the Condyle, Disc, RT (retrodiscal tissue), SLP, and ILP. 4/17/26 # KEY TMJ ANATOMY ### CAPSULAR LIGAMENTS | COMPARTMENTS **Fig 1.18. Temporomandibular Joint (Anterior View).** The following are identified: *AD*, Articular disc; *CL*, capsular ligament; *IC*, inferior joint cavity; *LDL*, lateral discal ligament; *MDL*, medial discal ligament; *SC*, superior joint cavity. **Fig. 1.19. Capsular Ligament (Lateral View).** Note that it extends anterior to include the articular eminence and encompass the entire articular surface of the joint. **Fig. 1.20. Temporomandibular Ligament (Lateral View).** Note that there are two distinct parts: the outer oblique portion (*OOP*) and the inner horizontal portion (*IHP*). The OOP limits normal rotational opening movement; the IHP limits posterior movement of the condyle and disc. (Modified from Dubrul EL: *Sicher's oral anatomy*, ed 7, St Louis, MO, 1980, The CV Mosby CO, pp 185.) **Fig. 1.22.** The mandible, temporomandibular joint, and accessory ligaments. (Stylomandibular ligament and Sphenomandibular ligament). *Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri.* --- # KEY TMJ ANATOMY ### SYNOVIAL MEMBRANE **Sagittal view** * **D** = disc * **E** = eminence * **C** = condyle * **U** = upper compartment * **L** = lower compartment *Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri.*   #### Ligamentous Structures - **Capsular Ligament:** Extends anteriorly to include the articular eminence and encompasses the entire articular surface of the joint. - **Temporomandibular Ligament:** Consists of two distinct parts: - Outer oblique portion (OOP): Limits normal rotational opening movement. - Inner horizontal portion (IHP): Limits posterior movement of the condyle and disc. - **Accessory Ligaments:** - Stylomandibular ligament - Sphenomandibular ligament - **Discal Ligaments:** - Lateral discal ligament (LDL) - Medial discal ligament (MDL) #### Joint Compartments - Superior joint cavity (SC): Upper compartment between the disc and the eminence. - Inferior joint cavity (IC): Lower compartment between the disc and the condyle. #### Synovial Membrane - Lines the joint cavities and produces synovial fluid for lubrication and nutrient transport. A composite medical illustration detailing Key TMJ Anatomy and Capsular Ligaments. The figure is divided into three sections: the left panel (Fig 1.18) shows an anterior view of the Temporomandibular Joint with labels for Articular disc (AD), capsular ligament (CL), inferior joint cavity (IC), lateral discal ligament (LDL), medial discal ligament (MDL), and superior joint cavity (SC). Below this is Fig 1.22 showing the mandible and accessory ligaments. The top center panel (Fig 1.19) displays a sagittal view of the Capsular Ligament extending anterior to include the articular eminence. The bottom center panel (Fig 1.20) illustrates the Temporomandibular Ligament in a sagittal view, identifying the outer oblique portion (OOP) limiting rotational opening and the inner horizontal portion (IHP) limiting posterior movement. The right column contains text headers 'KEY TMJ ANATOMY' and 'CAPSULAR LIGAMENTS COMPARTMENTS', along with a small inset photograph of the joint. A clinical photograph of the Temporomandibular Joint (TMJ) from a sagittal view, illustrating the Synovial Membrane. The image features yellow curved overlays highlighting specific anatomical structures labeled D (disc), E (eminence), C (condyle), U (upper compartment), and L (lower compartment). A legend on the right confirms these abbreviations. The photo provides a realistic visual representation of the joint compartments and membrane layers. **4/17/26** **TMJ BIOMECHANICS** - **Rotation** → **early opening (20-35 mm)** - **Translation** → **late opening** - Disc-condyle coordination and load distribution **TMJ closed** Lower joint compartment Condyle Articular disc Upper joint compartment Articular eminence Condyle of mandible **TMJ open** Lateral pterygoid Source: https://youtu.be/Nmg3xl13TY0?si=usgGvTQaNR0V4m9- Niekrash CE. 2021. Muscles of Mastication and the Temporomandibular Joint. In: Ferneini EM, Goupil MT, McNulty MA, Niekrash CE (eds). Applied Head and Neck Anatomy for the Facial Cosmetic Surgeon. Springer, Cham. https://doi.org/10.1007/978-3-030-57931-9_14 --- **TMJ BIOMECHANICS** - Disc morphology is critical for maintaining correct positioning during joint function - Normal shape, combined with intra-articular pressure, enables self-positioning of the disc → smooth and stable joint movement - Ligamentous attachments have minimal functional impact when disc morphology is intact - Significant alteration of disc morphology compromises this system - Ligaments do not stretch but become elongated with excessive force - Articular surfaces of TMJ are no longer maintained in constant contact - Resulting changes disrupt normal joint biomechanics - **Leads to development of TMJ dysfunction signs and symptoms** **Video:** https://youtu.be/utKxFD6a_6o?si=WZHIECHQDbDeL-mW   #### Normal Joint Movement - **Rotation:** Occurs during early opening (20-35 mm). - **Translation:** Occurs during late opening. - Function relies on disc-condyle coordination and effective load distribution. #### Role of Disc Morphology - Disc morphology is critical for maintaining correct positioning during joint function. - Normal shape combined with intra-articular pressure enables self-positioning of the disc, ensuring smooth and stable movement. - Ligamentous attachments have minimal functional impact when disc morphology is intact. #### Pathophysiological Changes - Significant alteration of disc morphology compromises the system. - Ligaments do not stretch but become elongated with excessive force. - Articular surfaces are no longer maintained in constant contact. - Disruption leads to the development of TMJ dysfunction signs and symptoms. Anatomical diagram illustrating the Temporomandibular Joint (TMJ) in two states: 'TMJ closed' and 'TMJ open'. The top panel shows the joint closed with labels for the Lower joint compartment, Condyle, Articular disc, Upper joint compartment, Articular eminence, Condyle of mandible, and Lateral pterygoid. The bottom panel shows the TMJ open, demonstrating the translation movement of the condyle relative to the articular eminence. A citation is present at the bottom right. Clinical photograph showing an endoscopic view inside the oral cavity or throat area. The image displays soft tissue structures, appearing reddish-brown and textured, likely representing the anatomy relevant to the mastication muscles or joint vicinity discussed in the context.   Circular flow diagram illustrating the 'AETIOLOGY OF INTRA-CAPSULAR TMJ DISORDERS'. The cycle connects several contributing factors in a clockwise direction: Microtrauma (repetitive low-grade loading), Macrotrauma (sudden overload injury), Ligament laxity/hypermobility, Systemic disease (rheumatoid arthritis, gout, etc.), Parafunction (diurnal, nocturnal), Emotional stress, and Deep pain input, which leads back to sleep-related factors. Conceptual figure titled 'INTRACAPSULAR DISORDERS'. It lists three categories: Derangements of the condyle-disc complex, Structural incompatibility of the articulating surfaces, and Inflammatory joint disorders. An orange arrow points from this list to a Venn diagram showing the relationship between 'PAIN' and 'DYSFUNCTION', highlighting their overlap. **4/17/26** 7 **CLINICAL FEATURES OF INTRACAPSULAR DISORDERS** * Joint pain (preauricular) * Clicking, popping, or crepitus * Restricted or deviated mouth opening * Locking (intermittent or persistent) * Pain on function (chewing, yawning) Okeson J. 2020. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier: Missouri. **PARAFUNCTION FEATURES** +/- occlusal wear 13 **CLASSIFICATION OF INTRACAPSULAR DISORDERS (DC-TMD)** 1. Disc displacement with reduction 2. Disc displacement with reduction with intermittent locking 3. Disc displacement without reduction with limited opening 4. Disc displacement without reduction without limited opening Figure: Taxonomy for TMDs Highlighted disorders are commonly seen and have validated diagnostic criteria Other disorders occur much less commonly and only have clinical criteria Source: Peck et al., 2014; Schifmann and Ohrbach, 2016. National Academy of Sciences https://www.orofacialtherapeutics.com/wp-content/uploads/2021/08/temporomandibular-disorders-explained-table.jpg 14   #### Common Clinical Signs - Joint pain (preauricular) - Clicking, popping, or crepitus - Restricted or deviated mouth opening - Locking (intermittent or persistent) - Pain on function (chewing, yawning) - Parafunction features (e.g., occlusal wear) #### DC-TMD Classification 1. Disc displacement with reduction 2. Disc displacement with reduction with intermittent locking 3. Disc displacement without reduction with limited opening 4. Disc displacement without reduction without limited opening Clinical photograph (Fig. 7.2) illustrating parafunctional features of the mouth. The image is split into two panels: Panel A shows evidence of cheek biting during sleep, characterized by a distinct chip and dark discoloration on the posterior tooth. Panel B displays a scalloped lateral border of the tongue conforming to the lingual surfaces of the mandibular teeth, indicating forced tongue pressure against the teeth during sleep. Flowchart titled 'Taxonomy for TMDs' depicting the classification of Temporomandibular Disorders. The diagram branches from a central header into three main columns: 'Temporomandibular Joint Disorders', 'Masticatory Muscle Disorders', and 'Headaches'. Each column lists specific sub-classifications such as Disc Displacement, Myalgia, and Orofacial Dyskinesia. An orange arrow highlights the connection between 'Disc Displacement with intermittent locking' in the left list and 'Disc Disorders' within the flowchart. **JOINT PAIN** * **Arthralgia** = **pain** in TMJ structure * Non-inflammatory * Arises from nociceptors in surrounding soft tissues: discal ligaments, capsular ligaments (**capsulitis**), retrodiscal tissues (**retrodiscitis**), synovial lining (**synovitis**) * Provoked by movement, function, parafunction or palpation * **Arthritis** = **inflammation** in TMJ structure * Inflammatory * Clinical signs: pain, swelling, warmth, erythema, altered function * Often associated with systemic inflammatory disease e.g. rheumatoid arthritis * Pain often more persistent and can occur at rest * **Effect:** * Limited mandibular movement * Protective co-contraction | 1. Temporomandibular Disorders | 1. Masticatory Muscle Disorders | 2. Headaches | | :--- | :--- | :--- | | **1. Joint Pain:**<br>• Arthralgia<br>• **Arthritis** | **1. Muscle Pain:**<br>• Myalgia<br>— Local myalgia<br>— Myofascial pain<br>— Myofascial pain *with referral*<br>• Tendinitis<br>• Myositis<br>• Spasm | **Headache Attributed to a TMD** | | **2. Joint Disorders:**<br>• Disc Disorders*<br>• Hypo-mobility Disorders<br>— Adhesions<br>— Ankylosis<br>• Hypermobility Disorders<br>— Dislocations | **2. Contracture** | **Associated Structures**<br>1. Coronoid Hyperplasia | | **3. Joint Diseases:**<br>• Degenerative Joint Disease<br>— Osteosarhrosis<br>— Osteoarthritis<br>• Systemic arthritides<br>• Condyl-lysis/Idiopathic condylar resorption<br>• Osteochondritis dissecan<br>• Osteonecrosis<br>• Neoplasm | **3. Hypertrophy** | | | **4. Fractures** | **4. Neoplasm** | | | **5. Congenital and Developmental Disorders:**<br>• Aplasia<br>• Hypoplasia | **5. Movement Disorders:**<br>• Orofacial dyskinesia<br>• Oromandibular | | | | **6. Masticatory Muscle Pain Attributed to Systemic/Central Pain Disorders:**<br>• Fibromyalgia/widespread | | Source: Peek et al., 2014; Schifmann and Ohrbach, 2016. National Academy of Sciences https://www.orofacialtherapeutics.com/wp-content/uploads/2021/08/temporomandibular-disorders-explained-table.jpg **JOINT DISORDERS AND DJD** * Conditions affecting TMJ structures: articular disc, articulating bony surfaces, supporting ligaments * Osteoarthrosis: non-inflammatory DJD * Osteoarthritis: inflammatory DJD | Joint Disorders | Joint Diseases | | :--- | :--- | | **Disc Disorders**<br>Displacement<br>— With Reduction<br>    — With intermittent locking<br>    — Without intermittent locking<br>    — With limited opening<br>    — Without limited opening<br>    — Perforation<br>— Hypermobility Disorders<br>    — Subluxation<br>    — Luxation (Dislocation)<br>— Others | **Degenerative Joint Disease (DJD)**<br>— Osteoarthrosis<br>— Osteoarthritis<br>— Others | Source: Peek et al., 2014; Schifmann and Ohrbach, 2016. National Academy of Sciences https://www.orofacialtherapeutics.com/wp-content/uploads/2021/08/temporomandibular-disorders-explained-table.jpg    #### Pain Classifications - **Arthralgia:** Pain in TMJ structures arising from nociceptors in soft tissues (ligaments, retrodiscal tissues, synovial lining). It is non-inflammatory and provoked by movement or palpation. - **Arthritis:** Inflammation in TMJ structures characterized by pain, swelling, warmth, and erythema. Often associated with systemic disease; pain may occur at rest. #### Clinical Effects of Pain - Limited mandibular movement - Protective co-contraction #### Joint Disorders and Degenerative Disease - **Joint Disorders:** Conditions affecting the articular disc, bony surfaces, and supporting ligaments (e.g., displacements, hypermobility). - **Joint Diseases:** Degenerative Joint Disease (DJD) including Osteoarthrosis (non-inflammatory) and Osteoarthritis (inflammatory). Hierarchical flowchart titled 'Temporomandibular Disorders' organizing conditions into three main categories: Temporomandibular Joint Disorders (including Arthralgia, Arthritis, Disc Disorders, etc.), Masticatory Muscle Disorders (including Myalgia, Contracture), and Headaches. Includes a side panel for Associated Structures. Flowchart diagram illustrating the classification of 'Joint Disorders'. It branches from a central node into 'Disc Disorders', 'Hypermobility Disorders', and 'Others'. The 'Disc Disorders' branch further details sub-classifications such as 'Displacement' with or without reduction and intermittent locking, while the 'Hypermobility Disorders' branch splits into 'Subluxation' and 'Luxation (Dislocation)'. Detailed hierarchical chart titled 'Temporomandibular Disorders' providing an in-depth breakdown of specific joint diseases like Degenerative Joint Disease (Osteoarthrosis, Osteoarthritis) and neoplasms, alongside muscle pain disorders and movement disorders. <html><body><table><tr><td colspan="2"><b>Condition</b></td><td><b>History (Patient Report)</b></td><td><b>Clinical Examination Findings</b></td></tr><tr><td>Disc Displacement with Reduction (DDwR)</td><td></td><td>Clicking or popping during opening and/or closing</td><td>Reproducible click on opening and/or closing (≥1 of 3 cycles)</td></tr><tr><td>DDwR with Intermittent Locking</td><td></td><td>Episodes of jaw <q>locking</q> with temporary inability to fully open</td><td>Click present + occasional limited opening that resolves</td></tr><tr><td>Disc Displacement without Reduction (with limited opening)</td><td></td><td>History of locking with sudden reduction in mouth opening</td><td>Limited opening (<40 mm), deviation to affected side, no click</td></tr><tr><td>Disc Displacement without Reduction (without limited opening)</td><td></td><td>Previous history of locking, now improved opening</td><td>Normal opening but persistent deflection, no click</td></tr><tr><td>Subluxation (hypermobility)</td><td></td><td>Jaw <q>goes out</q> on wide opening but self-reduces</td><td>Excessive opening with terminal <q>clunk</q> on closing</td></tr><tr><td>Luxation/Dislocation (open lock)</td><td></td><td>Inability to close mouth after wide opening</td><td>Patient presents with mouth open, requires assisted reduction</td></tr><tr><td>Degenerative Joint Disease (osteoarthritis / osteoarthrosis)</td><td></td><td>Joint noise (grating, grinding), may or may not have pain</td><td>Crepitus on movement (coarse, gravel-like sound)</td></tr><tr><td colspan="4"><b>DISC DISPLACEMENT WITH REDUCTION (DDWR)</b></td></tr><tr><td></td><td></td><td></td><td><ul><li>Normal range of mouth opening</li><li>Reproducible click on opening/closing, or opening/lateral/protrusive movements</li><li>Ipsilateral jaw deviation on opening with correction</li><li>+/- TMJ pain on movement, function, palpation</li><li></li></ul></td></tr><tr><td></td><td></td><td></td><td></td></tr></table></body></html>   #### Diagnostic Criteria Summary - **History:** Clicking or popping during opening and/or closing. - **Clinical Examination:** - Reproducible click on opening and/or closing (at least 1 of 3 cycles). - Normal range of mouth opening. - Ipsilateral jaw deviation on opening with correction. - Possible TMJ pain on movement, function, or palpation. Table titled 'JOINT DISORDERS AND DJD' with three columns: Condition, History (Patient Report), and Clinical Examination Findings. It lists various joint conditions such as Disc Displacement with Reduction (DDwR), DDwR with Intermittent Locking, Disc Displacement without Reduction (with limited opening), Subluxation (hypermobility), Luxation/Dislocation (open lock), and Degenerative Joint Disease (osteoarthritis / osteoarthrosis). Each row provides corresponding patient history and clinical findings. Diagram illustrating 'Opening movement of the mouth' for a healthy joint and two pathological conditions: ADDWR (Disc Displacement With Reduction) and ADDWOR (Disc Displacement Without Reduction). The diagram shows labeled anatomical structures including Temporal Disc, Condyle, and illustrates the displacement and reduction of the disc during mouth opening and closing movements. Arrows indicate the direction of movement and final positions. ## DDWR Characteristics | Pathophysiology Progression | Slide 19: Anatomical MRI / X-Ray Variations | Slide 20: Clinical Facial Symptoms / Pathophysiology Flowchart | | ---------------------------------------------------- | -------------------------------------------------------------- |    #### Pathophysiology Progression - Evaluation involves assessing anatomical variations via MRI or X-ray. - Clinical symptoms follow a progression flowchart from initial displacement to potential functional impairment. Fig. 8.11: Variations in Disc Displacements. Panel A shows a gross pathology specimen of the TMJ with a medial disc displacement (labeled 'Disc'). Panel B is an MRI showing a medial displaced disc. Panel C is an MRI showing a lateral disc displacement. Panels D, E, and F are schematic diagrams illustrating partial displacements of the medial or lateral portions of the disc. Clinical photos demonstrating facial symptoms associated with DDWR. Three panels show a patient's mouth opening to illustrate jaw deviation (ipsilateral) and the range of motion during movement. Pathophysiology flowchart for DDWR progression. The sequence flows from left to right through colored arrow segments: 'Repeated displacement & reduction' (Yellow) -> 'Morphological disc changes' (Blue) -> '↓ ability to self-position' (Grey) -> '↑ elongation of discal ligaments' (Green) -> 'Compromised joint stability' (Dark Green). 4/17/26 21 FIGURE: MRI showing anterior DD of a crumpled disc (D) in closed-mouth position and reduction in open-mouth position. DISC DISPLACEMENT WITH REDUCTION (DDWR) PDF Text: • MRI fat-saturation T2 sagittal sequence • Anterior DD of a crumpled disc (D) in closed-mouth position • Reduction of disc in open-mouth position • Effusion (red arrow) • Bilaminar zone of retrodiscal tissues (white arrow) DISC DISPLACEMENT WITH REDUCTION WITH INTERMITTENT LOCKING (DDWRIL) * Episodes of "catching" or intermittent locking * Normal mouth opening (may be intermittently limited during locking episodes) * +/- clicking on opening and closing (may become inconsistent) * +/- ipsilateral jaw deviation on opening with correction (when reduction occurs) * +/- TMJ pain on movement, function, palpation * Increased joint instability * > Risk of progression to a persistent mechanical restriction   #### Imaging Observations - MRI (fat-saturation T2 sagittal) may show anterior disc displacement of a crumpled disc in the closed-mouth position. - Reduction of the disc occurs in the open-mouth position. - Associated findings may include effusion and changes in the bilaminar zone. #### Clinical Presentation - Episodes of "catching" or intermittent locking. - Normal mouth opening, though intermittently limited during locking episodes. - Clicking on opening and closing (may become inconsistent). - Ipsilateral jaw deviation on opening with correction when reduction occurs. - Increased joint instability and risk of progression to persistent mechanical restriction. Clinical figure showing Disc Displacement with Reduction (DDWR). Left panel: Gross anatomical photo of the temporomandibular joint demonstrating anterior displacement of a crumpled disc. Right panel: MRI fat-saturation T2 sagittal sequence comparing closed-mouth position (anterior DD of a crumpled disc D) and open-mouth position (reduction of disc), with red arrow indicating effusion and white arrow pointing to the bilaminar zone of retrodiscal tissues. Diagram illustrating the opening movement of the mouth for 'Disc Displacement with Reduction with Intermittent Locking (DDWRIL)'. It compares a healthy joint against a displaced joint (ADDWR vs ADDWOR). The visual shows the temporal disc and condyle positions in closed mouth versus open mouth, highlighting the reduction of the disc during opening and the risk of increased joint instability and progression to persistent mechanical restriction. 4/17/26 # DISC DISPLACEMENT WITHOUT REDUCTION (DDWOR) WITH LIMITED OPENING (CLOSED LOCK) * Limited range of mouth opening (typically <35-40 mm; often 25-30 mm initially) * No clicking on opening and closing (loss of prior joint sounds) * Ipsilateral jaw deflection on opening (no correction) * Restricted contralateral excursion * +/- TMJ pain on movement, function, palpation **MECHANICAL PROBLEM** --- 23 # DISC DISPLACEMENT WITHOUT REDUCTION (DDWOR) WITH LIMITED OPENING (CLOSED LOCK) * Limited range of mouth opening (typically <35-40 mm; often 25-30 mm initially) * No clicking on opening and closing (loss of prior joint sounds) * Ipsilateral jaw deflection on opening (no correction) * Restricted contralateral excursion * +/- TMJ pain on movement, function, palpation **MECHANICAL PROBLEM** 24   #### Clinical Features (Closed Lock) - Limited range of mouth opening (typically <35-40 mm; often 25-30 mm initially). - No clicking on opening and closing (loss of prior joint sounds). - Ipsilateral jaw deflection on opening (no correction). - Restricted contralateral excursion. - Possible TMJ pain on movement, function, or palpation. - This represents a mechanical problem where the disc fails to reduce. Anatomical diagram illustrating the 'Opening movement of the mouth' for a healthy joint versus ADDWR (Anterior Disc Displacement Without Reduction). The top row shows a 'Healthy joint' with the disc in position during closed and open mouth states. The bottom rows depict the ADDWR condition: showing the displaced disc anterior to the condyle, restricted opening range ('CLOSED MOUTH'), and a specific callout arrow labeled 'Mechanical obstruction' pointing to the blocked joint space. Clinical figure set (labeled A and B) demonstrating DDWOR. Top panels show clinical photos of a patient's face with red vertical lines indicating jaw deflection/asymmetry during mouth opening. Bottom panels show gross anatomical specimens of the TMJ; Panel A highlights retrodiscal tissues (RT) and the disc position, while Panel B shows the joint space (JS) and disc relationship. Caption text explains the specimen findings regarding chronic disc displacement. DISC DISPLACEMENT WITHOUT REDUCTION (DDWOR) WITH LIMITED OPENING (CLOSED LOCK) DISC DISPLACEMENT WITHOUT REDUCTION (DDWOR) WITHOUT LIMITED OPENING | Feature | Description | | :--- | :--- | | History of prior limited opening (“closed lock”) | /// | | Normal or near-normal range of mouth opening (≥ 40 mm) | **opening is no longer limited** | | No clicking on opening and closing | // | | +/- ipsilateral jaw deflection | (may **reduce or become minimal**) | | +/- TMJ pain on movement, function, palpation | // | | **ADAPTED, NON-REDUCING DISC** | | :--- | | **Opening movement of the mouth** | | **Healthy joint** | **The same final position** | | **TEMPORAL** | **ADDWR** | | **CONDYLE** | **DISPLACED** | | **Temporal** | **Reduction** | | **DISPLACED** | **of the Disc** | | **CONDYLE** | **ADDWOR** | | **ADDWOR** | | *Disc still displaced* | **OPEN MOUTH** | | **CLOSED MOUTH** | |   #### Clinical Features - History of prior limited opening ("closed lock"). - Normal or near-normal range of mouth opening (≥ 40 mm) as opening is no longer limited. - No clicking on opening and closing. - Ipsilateral jaw deflection may reduce or become minimal. - Possible TMJ pain on movement, function, or palpation. - Characterized as an adapted, non-reducing disc. Figure showing 'DISC DISPLACEMENT WITHOUT REDUCTION (DDWOR) WITH LIMITED OPENING (CLOSED LOCK)' with two panels. Left panel shows an arthroscopic view of a crumpled disc in the TMJ. Right panel displays MRI fat-saturation T2 sagittal sequence images labeled 'CLOSED' and 'OPEN', illustrating anterior DDwoR of a crumpled disc (D). Red arrows indicate effusion in the superior joint space; dotted red arrow points to focal hyperintensity of anterior retrodiscal soft tissues; dashed red arrow indicates subtle erosion of the superior condylar cortex; open red arrow shows mild oedema of the marrow in the condyle. Diagram titled 'Opening movement of the mouth' illustrating three stages: Healthy joint, ADDWR (Adapted, Non-Reducing Disc), and ADDWOR (Disc Displacement Without Reduction Without Limited Opening). Each stage shows temporal bone and condyle anatomy with disc position changes during closed and open mouth movements. Labels include 'Temporal', 'Condyle', 'Healthy joint', 'ADDWR', 'ADDWOR', and callouts such as 'The same final position' and 'Disc still displaced'. Arrows depict reduction or lack thereof during opening. # Subluxation (Hypermobility) | **Subluxation (Hypermobility)** | **Image: Patient with a ruler measuring excessive jaw opening. (Sharma MR. 2012)** | **Video Links** | | :--- | :--- | :--- | | Excessive anterior translation of the condyle beyond the articular eminence | | **Video 1:** [https://www.tiktok.com/@mor10web/video/7367052507878591750?is_from_webapp=1&sender_device=pc](https://www.tiktok.com/@mor10web/video/7367052507878591750?is_from_webapp=1&sender_device=pc) | | Mouth opening > 40 mm | | **Video 2:** [https://www.instagram.com/reel/DPR1S5ajOty/?utm_source=ig_web_button_share_sheet](https://www.instagram.com/reel/DPR1S5ajOty/?utm_source=ig_web_button_share_sheet) | | Sudden “jump” or “thud” at maximal opening | | | | No clicking (not a disc displacement) | | | | Often visible preauricular depression at full opening | | | | Usually painless and not pathological | | | | May be associated with ligamentous laxity | | | | Repetitive episodes may predispose to joint instability or disc disorders | | **Key Concept:** Excessive movement rather than restricted movement | --- # Luxation (Open Lock) | **Luxation (Open Lock)** | **Image: A. Patient unable to close mouth. B. Panoramic radiograph showing condyles anterior to eminences. C. 3D CT reconstruction of joint destruction and right luxation. (Okeson J. 2020)** | **Source:** Source: [https://www.tiktok.com/discover/what-does-lockjaw-on-you-mean](https://www.tiktok.com/discover/what-does-lockjaw-on-you-mean) | | :--- | :--- | :--- | | Condyle displaced **anterior** to the articular eminence | | | | Unilateral or bilateral | | | | Inability to **close the mouth** | | | | Typically occurs after **wide opening** (yawning, dental procedures) | | | | Often preceded by **hypermobility / subluxation tendency** | | | | Patient may appear anxious and unable to self-reduce | | | | Not a disc disorder (**do not confuse with closed lock**) | | | | Usually non-pathological but requires **manual reduction** | | **CLINICAL EMERGENCY** |    #### Clinical Presentation - Excessive anterior translation of the condyle beyond the articular eminence. - Mouth opening > 40 mm. - Sudden "jump" or "thud" at maximal opening. - No clicking (not a disc displacement). - Often visible preauricular depression at full opening. - Usually painless and non-pathological; may be associated with ligamentous laxity. - Repetitive episodes may predispose to joint instability. Clinical photo of a patient with subluxation (hypermobility). The patient is shown with their mouth wide open, demonstrating excessive anterior translation of the condyle beyond the articular eminence. A ruler is placed vertically in front of the face to measure the mouth opening, which appears to exceed 40 mm. Composite figure illustrating Luxation (Open Lock) from Okeson J. 2020. Panel A shows a clinical photo of a patient unable to close their mouth. Panel B is a panoramic radiograph showing both condyles (C) displaced anterior to the articular eminences (AE). Panels C and D are 3D CT reconstructions showing destruction of the left temporomandibular joint and right luxation, with condyles anterior to the eminences. Close-up clinical photo of a patient's lower face with an overlaid text box reading 'Jaw Deviation & Locked Jaw'. This demonstrates the inability to close the mouth associated with luxation. # LUXATION (OPEN LOCK) * Condyle displaced **anterior to the articular eminence** * Inability to **close the mouth** * Typically occurs after **wide opening** (yawning, dental procedures) * Often preceded by **hypermobility / subluxation tendency** * Patient may appear anxious and unable to self-reduce * **Not a disc disorder** (do not confuse with closed lock) * Usually non-pathological but requires **manual reduction** **CLINICAL EMERGENCY** *** # MANAGEMENT OF LUXATION ### First-line: Syringe method * Place 5-10 mL syringe between posterior molars * Patient gently bites and rolls → allows mandible to self-reduce * No intraoral hand placement ### Manual reduction (if needed) * Thumbs on lower molars, fingers on mandible * Apply **downward then posterior force** * Key principle: disengage condyle → guide back into fossa * Use finger protection; assistant stabilises head ### Alternative techniques * **Wrist-pivot method:** uses wrist motion for easier reduction * **Extraoral methods:** no intraoral contact, but more difficult ### Adjuncts (if unsuccessful) * Local anaesthetic / auriculotemporal nerve block * Helps reduce pain and muscle spasm ### Post-reduction Care * Avoid wide opening (e.g. yawning) * Soft diet + NSAIDs * Warm/cold compresses * Specialist follow-up (risk of recurrence)    #### Clinical Presentation - Condyle displaced anterior to the articular eminence. - Inability to close the mouth. - Typically occurs after wide opening (yawning, dental procedures). - Often preceded by hypermobility or subluxation tendency. - Patient may appear anxious and unable to self-reduce. - This is a clinical emergency and not a disc disorder. #### Emergency Management - **Syringe Method (First-line):** Place 5-10 mL syringe between posterior molars; patient gently bites and rolls to allow self-reduction. - **Manual Reduction:** Thumbs on lower molars, apply downward then posterior force to disengage the condyle and guide it back into the fossa. - **Adjuncts:** Local anesthetic or auriculotemporal nerve block to reduce pain and muscle spasm. - **Post-reduction Care:** Avoid wide opening, soft diet, NSAIDs, and specialist follow-up. Radiographic and anatomical diagram illustrating Temporomandibular joint (TMJ) luxation (the disc is anteriorly displaced). Panel A shows a radiograph with the condyle (C) trapped in front of the articular eminence (AE). Panels B-D show cross-sectional views: B depicts normal anatomy; C shows maximum translation; D illustrates how the disc is pulled forward by the anterior capsular ligament during wide opening, trapping it. Anatomical diagrams illustrating Temporomandibular joint luxation (the disc is posteriorly displaced). Panel A shows normal resting position. Panel B shows maximum translated position with disc rotated posteriorly on the condyle. Panel C demonstrates how forcing the mouth open wider displaces the condyle over the disc, trapping it posteriorly as the disc space collapses. Image titled 'Syringe technique for TMJ dislocations', showing a patient with their mouth open while a syringe is inserted into the oral cavity to assist in reducing the jaw. 4/17/26 16 # INFLAMMATORY INTRACAPSULAR TMJ DISORDERS **Synovitis:** * Inflammation of synovial lining of joint recesses * Constant deep intracapsular pain * Pain increases with joint movement * Often due to irritation, microtrauma, or joint dysfunction * Clinically difficult to distinguish from capsulitis **Capsulitis:** * Inflammation of the capsular ligament * Localised tenderness at lateral pole of condyle * Pain present at rest and increases with function * Commonly associated with macrotrauma (e.g. wide opening injury) **Retrodiscitis:** * Inflammation of retrodiscal tissues * Constant dull aching pain, often worsened by clenching * May cause acute malocclusion if swelling displaces condyle * Typically associated with disc displacement or trauma 31 *** # DEGENERATIVE JOINT DISEASE (DJD) * **Crepitus** on opening and closing * **Limited** mouth opening (<35 mm) * **Osteoarthrosis:** DJD without pain (non-inflammatory); wear-and-repair imbalance → structural change * **Osteoarthritis:** DJD with pain (inflammatory) * Ipsilateral jaw **deflection** * TMJ pain on movement, function, palpation * May lead to functional limitation **Key Features:** * Destructive bony changes of articular surfaces (condyle & fossa) * Response to **chronic increased joint loading** * Cartilage softening (**chondromalacia**) → subchondral bone resorption * Progressive **bone erosion and remodelling** * Late radiographic changes: flattening, erosion, sclerosis **Associations:** * **Disc displacement without reduction** * **Disc perforation or loss of cushioning** * Increased loading of condyle on fossa accelerates degeneration > Early disease may be **clinically present but radiographically silent** > Reduced loading can allow **adaptive remodelling (osteoarthrosis)** ```mermaid graph LR A[Chronic mechanical overload] --> B[Destruction of articulating bony surfaces] B --> C[Functional impairment] ``` 32  #### Inflammatory Conditions - **Synovitis:** Inflammation of the synovial lining; constant deep pain that increases with movement. - **Capsulitis:** Inflammation of the capsular ligament; localized tenderness at the lateral pole, pain at rest and during function. - **Retrodiscitis:** Inflammation of retrodiscal tissues; constant dull aching pain worsened by clenching; may cause acute malocclusion. Flowchart diagram illustrating the progression of Degenerative Joint Disease (DJD). It consists of three connected nodes: 'Chronic mechanical overload' (yellow box) leading to 'Destruction of articulating bony surfaces' (blue box), which leads to 'Functional impairment' (grey box). # 4/17/26 ## DEGENERATIVE JOINT DISEASE (DJD) **5 radiographic findings:** | Sclerosis | **Erosion** | **Flattening** | | :--- | :--- | :--- | | **Pseudocyst** | **Osteophyte** | | • MRI proton density sagittal sequences • Loss of joint space, articular surface flattening, cortical thickening, osteophytosis, ossified body (white arrow) (a) • Anterior DD, bone on bone contact, synovial cysts (b) • Advanced DJD (c) • Red arrow shows large effusion distending the anterior recess of the superior joint space • White arrows indicate remnant of retrodiscal laminae • Dashed red arrow shows extensive erosion • Open red arrow shows extensive sub-articular marrow oedema • Glenoid fossa appears normal (often the case) Whyte A et al. Imaging of temporomandibular disorder and its mimics. 2020. J Medical Imaging and Radiation Oncology. Available from: https://doi.10.1111/1754-9485.13119 Source: https://youtu.be/MG_JqF1mNb0?si=CUYEFyf82PClNcdB 33 # DIAGNOSTIC APPROACH ## History 1. Clicking? 2. Grating? 3. Locking - transient, persistent? 4. Pain pattern 5. Habits ## Exam • Muscles of mastication (another lecture) • Range of motion (active, passive) • TMJ palpation, swelling, tenderness • TMJ range (rotation, translation) • TMJ sounds (click, crepitus) • Jaw deviation, deflection, asymmetry • Subluxation or dislocation • Direct pressure loading (bite on tongue- blade contralateral side ## Key features of internal derangement: **DDWR** → clicking • Early click: mild displacement • Late click: greater displacement • **Intermittent locking** → occasional catch **DDWoR** (closed lock) → limited opening **DDWoR** (no limit) → normal opening **Subluxation** → increased opening **Luxation** (open lock) → movement stuck **DJD** → crepitus **Perforation** → crepitus **Pain in loaded TMD** → retrodiscitis ## Investigations • TMJ MRI, CT, OPG • Serology if indicated Warburton G. 2021. **Internal Derangements** of the Temp_ oromandibular Joint. In: Bonanthaya K, Panneerselvam E, Manuel S, Kumar VV, Rai A. (eds) Oral and Maxillofacial Surgery for the Clinician. Springer, Singapore. https://doi.org/10.1007/978-981-15-1346-6_63 34 17   #### Clinical and Radiographic Features - **Crepitus:** Coarse, grating, or grinding joint noise. - **Limited Opening:** Typically <35 mm. - **Osteoarthrosis:** Non-inflammatory structural change (wear-and-repair imbalance). - **Osteoarthritis:** Inflammatory DJD with pain. - **Radiographic Findings:** Sclerosis, erosion, flattening, pseudocysts, and osteophytes. - **Pathophysiology:** Response to chronic mechanical overload leading to cartilage softening (chondromalacia) and progressive bone remodeling. Composite figure illustrating Degenerative Joint Disease (DJD) of the temporomandibular joint. The image includes: (1) a colored diagram listing '5 radiographic findings': Sclerosis, Erosion, Flattening, Pseudocyst, and Osteophyte; (2) a clinical photo on the left showing an intra-oral view with tissue pathology; and (3) a composite medical imaging panel on the right containing four sub-images labeled (a), (b), (c), and (d). These include MRI proton density sagittal sequences and CT scans. Red and white arrows in the images point to specific pathologies such as ossified body, anterior DD, bone-on-bone contact, synovial cysts, large effusion, retrodiscal laminae remnants, erosion, and marrow oedema. A composite clinical photograph demonstrating the physical examination of the Temporomandibular Joint (TMJ). The top-left image shows palpation of the joint area with gloved hands. The top-right image depicts jaw deviation assessment using a ruler. The bottom section displays additional views including occlusion and a small X-ray insert. Text overlays on the images list exam parameters such as swelling, tenderness, hinge & translation, symmetry of motion, jaw deviation, ROM (subluxation/dislocation), clicks/crepitations, and timing of click. # RADIOGRAPHIC EXAM ## Imaging modalities: * **Plain radiographs / CT $\rightarrow$ assess bony changes** * **MRI = gold standard for disc position & soft tissues (~90% accuracy)** * **MRI protocol:** **T1 + T2 sequences**, closed & open mouth views, additional: **fat-suppressed / STIR $\rightarrow$ detect oedema** ## What MRI evaluates: * **Bone**: sclerosis, erosions, flattening, osteophytes, cortical breaks * **Disc**: position, shape, size, continuity (perforation) * **Joint space**: collapse * **Effusion**: best seen on **T2** * **Disc displacement patterns** ## Key interpretation point: * Compare **closed vs open mouth** * Determines **disc displacement and reducibility** **(a–c) MRI scan—T1 and T2 images in closed and open mouth positions.** **(a) Normal disc position.** **(b) Anterior disc displacement with reduction.** **(c) Anterior disc displacement without reduction and superior joint space effusion** --- # DECISION TREE | **HISTORY & EXAMINATION** | **Start at each blue-outline box** | | :--- | :--- | | *Current TMJ noises by history [SQ8]* **OR** *Noise detected by patient during examination [E6 OR E7]* | *Current TMJ noises by history [SQ8]* **OR** *Noise detected by patient during examination [E6 OR E7]* | | $\downarrow$ **No** | $\downarrow$ **Yes** | | | **Degenerative Joint Disorder** | | $\downarrow$ **No** | *Prior jaw locking in closed position [SQ9]* **AND** *Interference in mastication [SQ10]* | | *Opening & closing click [E6]* **OR** *[ Opening or closing click [E6] AND Excursive or protrusive click [E7] ]* | $\downarrow$ **Yes** | | $\downarrow$ **Yes** | *Disc displacement without reduction, with limited opening* | | *Current intermittent locking with limited opening [SQ11=yes & SQ12=no]* | $\downarrow$ **Yes** | | $\downarrow$ **Yes** | *MAO $\ge$ 40mm (including overbite) [E4C]* | | *If present in clinic: Maneuver required to open mouth [E8] else go to 'Yes'* | $\downarrow$ **Yes** | | $\downarrow$ **No** | | | | **Disc displacement without reduction without limited opening** | | <br>Investigate other diagnoses | | | $\downarrow$ **No** | | | *Disc displacement with reduction* | | | $\downarrow$ **Yes** | | | **IMAGING**<br>**CLINICAL DIAGNOSIS** | **Confirm by MRI when indicated** | | *Disc displacement with reduction, with intermittent locking* | | | $\downarrow$ **No** | *Confirm by CT when indicated* | *(Note: The "Investigate other diagnoses" branch is at the end of the path starting with "History & Examination - No")*   #### Imaging Modalities - **Plain Radiographs / CT:** Used to assess bony changes. - **MRI:** Gold standard for disc position and soft tissues (~90% accuracy). - T1 and T2 sequences evaluate bone, disc position/shape, joint space, and effusion. - Comparison of closed vs. open mouth views determines reducibility. #### Diagnostic Decision Tree - Evaluation starts with history of joint noises and locking. - Clinical examination confirms presence of clicks or crepitus. - Imaging (MRI or CT) is used to confirm clinical diagnoses of disc displacements or degenerative disorders. Labelled composite figure of MRI scans showing three rows labeled (a-c). The top row shows T1 Closed and T1 Open views. The middle row shows T1 Closed, T1 Open, and T2 views. The bottom row shows T1 Closed, T1 Open, and T2 views. Arrows point to specific anatomical features such as the disc, condyle, and effusion. Caption reads: '(a-c) MRI scan—T1 and T2 images in closed and open mouth positions. (a) Normal disc position. (b) Anterior disc displacement with reduction. (c) Anterior disc displacement without reduction and superior joint space effusion'. Flowchart titled 'Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): Diagnostic Decision Tree'. It branches into 'Intra-articular Joint Disorders' and 'Degenerative Joint Disorder' based on history and examination findings like TMJ noises, jaw locking, and clicks. Nodes include decision points like 'MAO ≥ 40mm' and outcomes leading to clinical diagnoses such as 'Disc displacement with reduction' or 'Degenerative joint disease', culminating in confirmation steps like 'Confirm by MRI when indicated'. # Management * Education, reassurance * Pain free jaw function * Nutrient-dense softer diet * Habit control * Thermotherapy * Physical therapy (jaw exercises, massage, other) * Stress management * Oral appliance * Pharmacotherapy (NSAIDs, muscle relaxants, TCAs, SSRIs, botox) * Specialist referral for further assessment and management # Specialist Management <table> <thead> <tr> <th> <b>Indications for referral:</b> </th> <th> <b>Specialist management options:</b> </th> </tr> </thead> <tbody> <tr> <td> <ul> <li> Persistent symptoms despite conservative management </li> <li> Recurrent locking or restricted mouth opening </li> <li> Suspected internal derangement or degenerative joint disease </li> <li> Significant functional limitation or progressive symptoms </li> <li> Diagnostic uncertainty </li> </ul> </td> <td> <ul> <li> Conservative measures </li> <li> Custom stabilisation splints </li> <li> Targeted physiotherapy programs </li> <li> Pharmacological optimisation </li> <li> Management of DJD </li> <li> Intra-articular injections (e.g. corticosteroids) </li> <li> Arthrocentesis (joint lavage) </li> <li> Arthroscopy (adhesiolysis, synovial assessment) </li> </ul> </td> </tr> <tr> <td colspan="2"> <b>Advanced / surgical (rare):</b> </td> </tr> <tr> <td> <ul> <li> Open joint surgery for refractory cases </li> </ul> </td> <td> Disc repositioning or repair procedures </td> </tr> </tbody> </table> #### Conservative Measures - Education and reassurance. - Nutrient-dense soft diet and habit control. - Thermotherapy and physical therapy (jaw exercises, massage). - Stress management and oral appliances. - Pharmacotherapy: NSAIDs, muscle relaxants, TCAs, SSRIs, or Botox. #### Specialist Referral and Procedures - **Indications:** Persistent symptoms, recurrent locking, diagnostic uncertainty, or significant functional limitation. - **Specialist Options:** - Custom stabilization splints. - Intra-articular injections (e.g., corticosteroids). - Arthrocentesis (joint lavage). - Arthroscopy (adhesiolysis, synovial assessment). - Open joint surgery (rare) for disc repositioning or repair. 4/17/26 PROGNOSTIC FACTORS ```mermaid graph TD Compliance --> Severity Severity --> Chronicity Chronicity --> Psychosocial_factors Psychosocial_factors --> Compliance Psychosocial_factors[Psychosocial factors] ``` 39 THANK YOU Supeetha Suntharamoorthy Supeetha.Suntharamoorthy@uwa.edu.au 40 20  #### Factors Influencing Outcome - Compliance - Severity of the disorder - Chronicity - Psychosocial factors Cyclical diagram illustrating 'PROGNOSTIC FACTORS' with four connected nodes: Compliance → Severity → Chronicity → Psychosocial factors → Compliance. Each node is labeled and connected by directional arrows in different colors (green, gold, blue-gray). The diagram visually represents a feedback loop among these factors. [^1]: Original PDF page 1: [[L29 TMJ Intracapsular Disorders.pdf#page=1|L29 TMJ Intracapsular Disorders, p.1]] [^2]: Original PDF page 2: [[L29 TMJ Intracapsular Disorders.pdf#page=2|L29 TMJ Intracapsular Disorders, p.2]] [^3]: Original PDF page 3: [[L29 TMJ Intracapsular Disorders.pdf#page=3|L29 TMJ Intracapsular Disorders, p.3]] [^4]: Original PDF page 4: [[L29 TMJ Intracapsular Disorders.pdf#page=4|L29 TMJ Intracapsular Disorders, p.4]] [^5]: Original PDF page 5: [[L29 TMJ Intracapsular Disorders.pdf#page=5|L29 TMJ Intracapsular Disorders, p.5]] [^6]: Original PDF page 6: [[L29 TMJ Intracapsular Disorders.pdf#page=6|L29 TMJ Intracapsular Disorders, p.6]] [^7]: Original PDF page 7: [[L29 TMJ Intracapsular Disorders.pdf#page=7|L29 TMJ Intracapsular Disorders, p.7]] [^8]: Original PDF page 8: [[L29 TMJ Intracapsular Disorders.pdf#page=8|L29 TMJ Intracapsular Disorders, p.8]] [^9]: Original PDF page 9: [[L29 TMJ Intracapsular Disorders.pdf#page=9|L29 TMJ Intracapsular Disorders, p.9]] [^10]: Original PDF page 10: [[L29 TMJ Intracapsular Disorders.pdf#page=10|L29 TMJ Intracapsular Disorders, p.10]] [^11]: Original PDF page 11: [[L29 TMJ Intracapsular Disorders.pdf#page=11|L29 TMJ Intracapsular Disorders, p.11]] [^12]: Original PDF page 12: [[L29 TMJ Intracapsular Disorders.pdf#page=12|L29 TMJ Intracapsular Disorders, p.12]] [^13]: Original PDF page 13: [[L29 TMJ Intracapsular Disorders.pdf#page=13|L29 TMJ Intracapsular Disorders, p.13]] [^14]: Original PDF page 14: [[L29 TMJ Intracapsular Disorders.pdf#page=14|L29 TMJ Intracapsular Disorders, p.14]] [^15]: Original PDF page 15: [[L29 TMJ Intracapsular Disorders.pdf#page=15|L29 TMJ Intracapsular Disorders, p.15]] [^16]: Original PDF page 16: [[L29 TMJ Intracapsular Disorders.pdf#page=16|L29 TMJ Intracapsular Disorders, p.16]] [^17]: Original PDF page 17: [[L29 TMJ Intracapsular Disorders.pdf#page=17|L29 TMJ Intracapsular Disorders, p.17]] [^18]: Original PDF page 18: [[L29 TMJ Intracapsular Disorders.pdf#page=18|L29 TMJ Intracapsular Disorders, p.18]] [^19]: Original PDF page 19: [[L29 TMJ Intracapsular Disorders.pdf#page=19|L29 TMJ Intracapsular Disorders, p.19]] [^20]: Original PDF page 20: [[L29 TMJ Intracapsular Disorders.pdf#page=20|L29 TMJ Intracapsular Disorders, p.20]]