Tempro-mandibular joint

-Def :
Compound joint that represent articulation between head of mandible “ condyle “
below and both mandibular fossa and articular eminence above .
-Can be classified anatomically and functionally
A- anatomically :
 It is diarthroidal joint .
 Also synovial joint lined by synovial membrane which secret synovial fluid .
 Function of synovial fluid ;
 Lubrication
 Supplies the the metabolic and functional needs fo non-
vascularized internal joint structures.
B-functional :
Compound joint compossed of four articulating
surfaces ;
1- articular facet of tempral bone .
2- mandibular condyle .
3- superior surface of articular disc .
4- inferior surface of articular disc .

-Articular disc divided the joint into two component :

1) Lower compartment ; permits hinge and rotation > termed “ gynglimoid
“.
2) Upper compartment ; permits sliding and translator movement > termed
“ artho “
The TMJ as whole can be termed ( gynglimo arthoidal joint )

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- tempero-mandibular joint is unique joint because :
1) It articulate bilaterally at the same time .
2) Allow hinge , translator , side to side , protrusion and retrusion movement
3) It is articulator surface caused by non-innerveted ( no nerve or blood fibro-
cartilageneus tiisue .
N.B get it’s nerve and blood supply from :
a- collaterals. b- capsule. c- mascular innervation .

Anatomy of TMJ : A-Bony part proper . B- Soft tissue component .

A- bony part proper : which divided into ;

1) Temoral part
2) Mandibular part

1- temoral part
a-mandibular fossa :
boundaries of mandibular fossa ;
 Articular eminence ( antcriorly )
 Glenoid tubercle ( postcriorly )
 Floor of fossa ( superiorly ) (above )

b- articular eminence has :

antcrior slope , postcrior slope and summite .

2- mandibular part
-condylar head :
 In closed position ; the condyle centrally located in fossa .

 In maximum mouth opening ; the condyle within the confinement of

fossa . so that summit of eminence over the center of head of condyle .
Thus , the TMJ is articulation between mandibular condyle and temporal bone.
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-Anatomical landmarks of mandible :
“ Mandible has two rami and the body “
-features of frontal view ;
1) Symphesis ment .
2) Mental foramen .
3) Angle of mandible ( everted , invertd ) .
4) External oblique ridge .
5) Coronoid process .
6) Sigmoid notch .
7) Condyle .

-features of lingual view :

1) Genial tubercle ( 2 superior and 2 inferior ) ; bony projection give origin of
genoglossal and genohyoid muscle .
*significant of genoglossal muscle ; in case of sympheseal fracture , tongue
retruded into pharynx causing obstruction of airway .
2) Mylohyoid groove ; give attachment of mylohyoid muscle bilaterally >
diaphragm oris
3) Groove for lingual nerve ; which has close proximity to root of third
molar . thus carful must be taken when extracting this teeth .
4) Inferior alveolar foramen and canal .
5) Lingula .
6) Sublingual salivary gland space .
7) Submandibular salivary gland space .
8) Median pterygoid fossa .

-features from top view :

Condyles in the same person rarly to be identicle , because right mandibular
fossa differ from that left side .

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B- Soft tissue component :
1- disc , meniscas , cartilage . 2-muscles . 3-ligaments. 4-capsule
.
1-DISC , meniscas , cartilage :
Intervening substance that lubricate the movement to be harmonious ,
smooth ana easy to be done .
-disc has complex anatomy :
To accommodate the movement which has been done by joint “ hinge ,
translator , side to side , protrusion and rutrusion movememt “ .
-there is special harmony “ orientation “ between the condyle and disc
otherwise iubricateed and smooth movement is impaired .
-disc anatomy must accommodate the harmonious movement between condyle
and fossa to allow ; smooth , harmonious and lubricated movements .

-Anatomy of the disc :

1) Anterior band ; which is more thick .
2) Inter mediate zone ; the most thinnest part of disc .
3) Posterior band ; which is the thickest part .
4) Retro discal tissue “ bi laminar zone “ which divided into
a- upper elastic attachment .
b- lower fibrous attachment .
-Anatomy in position : when the condyle is centrally located in fossa and you are
In physiologic rest position “ free way space “ 2-3 mm
Between upper and lower jaws .
-anterior band ; so near to the summite of eminence .
-Inter mediate zone ; which determine whether the disc in proper position or
not .
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 - it appear to be dislodged between posterior slope of eminence and
antro superior part of head of condyle .
- posterior band ; centrally located over the head of the condyle .
- retro discal tissue ; relaxed “ redundant “ in posterior attachment and
Divided into upper elastic and lower fibrous attachment .
N.B : the articular disc look like school’s “ pupil’s “ cap or Jockey’s cap .

2-Muscles :
a) Basic muscles of mastication .
b) Accessory muscle of mastication .
c) Other muscles of head and neck and neck area .

A- basics muscles of mastication :

There is four in number ;
 Lateral pterygoid muscle “ depressor “ ( opening muscle )
 Massater , temporal medial pterygoid muscles ( elevator or closing
muscles )
1) Lateral pterygoid muscle ;
-origin ;
 Upper superior head ; from infra temporal surface of gastric wing
of sphenoid .
 Lower inferior head ; from lateral surface of lateral pterygoid plate ,
infra temporal crest .
Both upper and lower head , sweep toward insertion .
- insertion ;
 Upper head ; disc and capsule .
 Lower head ; condyler fovea .
- action ;
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  opening “ depression “ retrusion and side to side .
 during muscle contraction the insertion move toward the origin
,thus condyle exit the fossa toward the origin “pterygoid
plate > opening .
2) masseter muscle :
- origin ; infro-medial part of zygomatic arch .
- insertion ; outer part of angle of the mandible .
- action ; closure and protrusion .

3) Medial pterygoid muscle :

- origin ;
 Superfacial head ; from maxillary tuberosity .
 Deep head ; “ main origin “ from medial surface of lateral
ptregoid plate and pterygoid fossa .
Both superfacial and deep head angaging the inferior head of lateral
ptregoid muscle .
- insertion ; rough medial surface of angle .
- action ; closure , protrusion and side to side movement .
4) Temporalis muscle : “ fan shape muscle “
-origin ; temporal lines , sweep under zygomatic arch toward the
Insertion .
- insertion ; antero-superior , medial and lateral part of chronoid
process .
- action ; clouser and retrusion

B-Accessory muscles of mastication :

They act as depressor muscles thus augment the action of lateral pterygoid
muscle .

-they are four in number :

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 1) Digastric muscle ; has anterior belly and posterior belly of digastric and
suspended into hyoid bone .
2) mylohyoid muscle ; from diaphragm oris “ floor of the mouth “ .
3) stylo hyoid muscle .
4) genio hyoid muscle .

C- Other muscles of head and neck and neck area :

1) sternomastoid muscle ; originated from sternum and
inserted into mastoid process
2) trapezius muscle ; originated from occipital bone
Inserted into clavicle and scapula .
3) splenius capitis ; originated from occipital bone and Inserted into back of
mastoid process and lateral part of superior nuchal line .
N.B: thus muscles may subjected to pain in case of temporal-mandibular Joint
Disorder .
3- Ligaments :
- Act as brake thus control muscle activity , to avoid hypermobility even during
speech .
-there are two groups of ligaments :
A-functional ligaments ;
1) collateral or discal ligament .
2) capsular ligaments .
3) tempora-mandibular joint ligament .

B- Accessory ligaments :

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 1) spheno-mandibular ligament .
2) stylo-mandibular ligament .

4- Capsule : fan shape originated from zygomatic arch and sweep down ward
To cover the head of condyle and lateral surfaces of the condyle .

N.B :
 Opening muscles “ depressor :
1- Lateral pterygoid muscle .
2- Accessory muscles of mastication .
 Closing muscle :
1-masseter muscle .
2-medial pterygoid muscle .
3- temporal muscle .
 Muscle of retrusion :
1- Lateral pterygoid muscle .
2- temporal muscle .
 Muscle of protrusion :
1- -masseter muscle .
2-medial pterygoid muscle .
 Muscle of side to side movements :
1-medial pterygoid muscle .
2- Lateral pterygoid muscle .
 Masseter muscle ( closure , protrusion ) opposite action of lateral
pterygoid muscle ( opening and retrusion )
 Medial pterygoid ( protrusion ) opposite action of temporalies muscle
( retrusion )

-Innervation of Tempro-mandibular joint :

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  Nerve supply ;
Branches from auricle-temporal nerve with contribution from
Massetric nerve and posterior deep temporal nerve .
 Blood supply :
A- Arterial blood supply ; branches from \
 Superfacial temporal artery .
 Massetric artery .
 Maxillary artery .
B- Venous blood supply ;
Rich plexus of vein on posterior aspect of joint in association
with retro discal tissue .

Opening cycle
A- at rest :
 In normal physiological rest position ana all over the time , disc preceeding
to the condyle 1-2 mm to achive harmonious , smooth and lubricated
movement .
 At rest the condyle is centrally located in the fossa and inter medial zone is
dislodged between posterior slope of the eminence and antero-superior
part of the head of the condyle .
B-During opening :
 Hing movement or rotational movement .
 It is movement of the disc over the head of the condyle to achive
preparation for translation , for exitance of condyle from the fossa .
C-During movement opening :
1- contraction of the upper and lower head of lateral pterygoid muscle occur
pulling the disc and condyle the pulling of the disc is controlled by retro
discal tiisue .
2- Gradual contraction of the upper and lower head of lateral pterygoid muscle
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 Occure which cause ;
 More forward displacement of disc which cause more strain of retro
discal tiisue up to maximum mouth opening .
 Exit of condyle from fossa .
Thus , mandible assure maximum opening position in which ;
 Maximum stretch of retroduscal tissue .
 Anterior band is located between summite and superior part of the
condyle .
 Maximum contraction of lateral pterygoid muscle .
 Relaxation of MMT muscle .

D- During closure :
1- Maximum relaxation of lateral pterygoid muscle .
2- retro discal tissue pull the disc backward toward it .
3- condyle return back to the fossa .

*guid of the action : is centric relation .

- any disorder of the factors responsible for harmony will result in tempero-
mandibular joint diseases .

Tempro-mandibular joint disorder .

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-Condition in which there is disorder of any factors which responsible for
harmony of TMJ .
-these factors are :
1-bone . 2- muscle . 3 ligaments. 4-Disc. 5- centric relation .
Thus ,
 disc herniation or tearing of collateral ligament
 osteo-artheritic of bone
 malocclusion or loss of vertical dimension
all may cause TMD .
- in case of disharmony due to early loss of posterior teeth , the disc
continuously attempt to assume new position , which cause hypermobility , thus
this patient mre liable to hypermobility .

Ankylosis
 Def :
Stiffness of joint or locked joint in which there is chronic limitation of
mouth opening .

 Causes :
1-Truma ; is more than 80 % of cases .
2- Infection ; as ostitis media , reaction response of body toward this
infection is formation of arbitrary ,
-pain from infection not permiting opening of the mouth
which in turn allow organization of clot .
3- delivary forceps :
Which cause crushing of condyle during the development .
4- ankylotic sponellytis ; inflammation as chronic osteo arthiritis .
5- post operative : as complication of TMJ surgery .
6-tumor : as osteo sarcoma .

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  Type of ankyloses :
A- False ankylosis ;
Extra articular ankylosis treated once the cause is removed .
B- True ankylosis ;
In which there is intra-capsular bonr precipitation “hemo artherosis “
 Type of true ankylosis :
1) Fibrous ; in which cause limitation of mouth opening
, easily to treated
2) Bony ; in which there is bone precipitation “hemo artherosis “

 Pathogenesis : truma causing inter capsular fracture of condyle , thus blood

effused into joint space by capsule and disc is displaced according to site of
truma >>> blood clot formation and if neglected organization of clot occur ,
result in fibrous tissue formation and finally bone Is formed “hemo
artherosis” .

 Type of ankylosis according to number of affected condyle :

a) Unilateral ankylosis ;
- in which one condyle grow and other form ankylotic mass .
- clinical picture :
1. Shifting from lower jaw toward affected side during
opening .
2. Short ramus and boby .
3. Accentuation of antiglenoid notch “concaue “ due to pull
action of mastication muscles “ MMT “ is upward .

b) Bilateral ankylosis ;
- in which give typical “ Bird face appearance “

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 - clinical picture :
1. Short ramus and boby bilaterally .
2. Prominent mandibulare angle bilaterally .
3. Accentuation of antiglenoid notch bilaterally .
4. Malocclusion “ antcrior open bite “
5. Protrusion of maxilla and retrusion of mandible
“ retrogenia and retrognathia “
N.B : in case of long standing ankylosis : coronoid hyper plasia my occure
because temporalis muscle exerted pull on coronoid process .

 Diagnosis and treatment of ankylosis :

A- diagnosis :
 Clonical pictures : 1- bilateral . 2-unilateral .
1-bilateral :
 clinical picture ; from frontal-lateral view .
 abnormal picture ; typical brid face appearance .
 face ;
-upper third > protruded maxilla .
- lower third > retruded mandible .
- teeth > prognathism .
 Mandible :
1-Short ramus and boby bilaterally .
2- Prominent mandibulare angle bilaterally .
3- Accentuation of antiglenoid notch bilaterally .
4- Malocclusion , crowding , carious teeth “ antcrior open bite “ .
5- Protrusion of maxilla
6- retrusion of mandible due to impaired it is growth that stimulate
function .

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2- unilateral :
 All signs of bilateral ankylosis are found in unilateral ankylosis , but
occurs unilaterally .
 In addition ; shift of lower jaw toward the affecting side during opening .

 Radiografic picture :
1. Scelortic mass at joint area .
2. Short ramus body .
3. Prominent angle .
4. Lengthed coronoid .
5. Accentuation of antiglenoid .
6. If unilateral > shifting toward affecting side

 Surgical treatment of ankylosis :

- Indural approach :
on the wall of ear and after exposure , the boundaries of condyle is
determined superiorly ,inferiorly , anteriorly , posteriorly , then method of
surgical treatment depend on type of ankylosis .
- methods of surgical treatment differ according to type of ankylosis :
1. Gap arthroplasty .
2. Condylectomy .
3. Coronoidectomy .
4. Pterygo-massetric sling release to avoid relapse.

1- Gap arthroplasty :

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  Indication ;
a-in case of bony anylosis .
b-anatomy of condyle are not identified .
c- condyle completely fused to fossa .
d- condyle has no demarcation , articulation .
 Technique ;
- removal 1-2 cm segment of ankylotic mass by two parallel cuts from
sigmoid noth obliquely 45 degree to post border of ramus .
2- condylectomy :
 indiction ; - in case of fibrous ankylosis.
- condyle can de identified .
 technique ; removal of condyle .
3- coronoidectomy : due to hyper plasia of coronoid .
4- Pterygo-massetric sling release to avoid relapse :
 technique ;
- by mucoperiosteal elevator .
- introduced it under inferior border and release the sling formed by
( medial pterygoid muscle , masseter muscle )
5- cost chondral graft :
 indication ;
-used to length ramus and act as anew joint replacement .
-in unilateral ankylosis > shift toward affected side thus cost chondral
Graftis done which act as a new joint replacement .
-stimulate mandible for growth .
 technique ; -segment from costal bone contain cartilage , put it in created
gap to avoid recurrence .
- or by bone from againg crest , but cost chondral graft more
accepted .

6- Distraction osteogenesis : to correct facial hight and occlusion .

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  application of distraction osteogenesis ;
 before releasing of ankylosis .
 after releasing of ankylosis .
 at same time in operation .
7- corrective orthognathic surgery :
 used in bilateral ankylosis , to correct anterior open bite .

N.B

 Post-opreative , the patient open his mouth by accessory muscle of

mastication , why ? because the action of lateral pterygoid muscle
on condyle is eliminated by removal of condyle in surgery .
 Assure that facial nerve not injured during operation , by askin the
patient to below his mouth and to move his eue brows .
 Cynstosis : fusion between medial surface of mandible and
pterygoid plate .

 Recurrent of ankylosis may be due to :

1. Insufficient removal of bone “ inadequate incision “
2. Delayed physio therapy .
3. Infection .

 Complication of surgical treatment of ankylosis :

1. Bleeding .
2. Infection .
3. Facial nerve paralysis .
4. Frey’s syndrome “ auriculo-temporal syndrome “ .
5. Performation of medial cranial fossa .

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 Internal derangement of TMJ
 Def
Loss of harmony between condylar movement and disc position and manifested
by clicking with or without reduction, later complicated by dislocation.

 Stage of internal derangement :

1) Anterior disc displacement with reduction;
The disc displacement within the confinement of fossa in direction of muscle
pull and the patient can open or close by him self.
-if the patient not follow the instruction
2) Anterior disc displacement without reduction occur;
In this case there is :
a) Reduction of retrodiscal tissue ”Relaxation”.
b) Disc displaced more forward.
Thus patient can open by himself and opening process is completed but in
closure the process impaired.
This patient can not open by himself

3) Dislocation “pt himself can not reduce the mandible manually;

The reduction of mandible in anterior disc placement without reduction require
downward, backward and upward movement in order to creat space for imprison
disc to return back to it is position followed by condylar movement in centric
relation.

 N.B:
 In anterior disc displacement with reduction in closed position retro discal
tissue with center of condyle .
 In anterior disc displacement without reduction in maximum opening all part
of disc infront of condyle and codyle articulate with retro discal tissue
“locking”.

 Management pt. with internal derangement :

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 Clinical picture…
1) Pain: during function, mastication, opening or even speech.
2) Clicking : early alarm of disturbed function.
3) Disturbed occlusion as
-premature contact.
-loss of occlusal table.

4) Limited mouth opening :

Most common in chronic due to adhesion between disc &capsule or disc and
fossa.

5) Inability to eat: which lead to change habit of eaten.

 Radiographic interpenetation…
A. Plain: not has any relation to disc and it is position.
1. Panorama “standard”: it is show :
 Upper& lower jaws.
 Maxillary sinus.
 Inferior alveolar canal.
 Mental foremen.
 Condyle.
 Joint space.
But disc position in relation to condyle not determined. Only disc position
determined in dynamic movements, closed or open position.

2. Tomogram:
Special view of TMJ in closed and open position. Determined the condylar
position and relation of joint space to condylar position by:
 Imaging left side in closed and open position.
 Imaging right side in closed and open position.
Then comparison is done.

B. Advanced :
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1. MRI “magnetic recorance imaging”
Normally concerned with recongenation of soft tissue lesion, disc , tongue mass,
cheek, lesiosin , infratemporal fossa, floor of the mouth and lesion of masseter
and temporalis.
MRI used mainly for imaging of TMJ to determine :
 Disc position in details.
 Disc texture.
-The following can be determined from MRI:
I. Disc position whether:
-in normal position.
- anterior position.
-dislocation.
II. Disc horniation and perforation
2. C.T: defects in osseous tissue.
 In maximum mouth opening :
Normally summite is with center of condyle.

 In hyper mobility:
Posterior slop of the condyle is anterior and superior to the eminence. Due to:
1. Hyper activity of lateral ptreygoid m.
2. Luxation of ligament .
3. Loss of posterior table or loss of anterior teeth thus in order to approximate
the upper and lower jaws together recissetate forward protrusion of
mandible by repeatation of this action habitual hypermobility occure.
 :::Differance between hypermobility and dislocation:::
- in hyper mobility :
Patient lower jaw can be reduced mainly by himself.
-in dislocation :
Patient jaw can not reduced manually by himself and require downward and
upward movement in recent cases.

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But later in continuty of this condition fibrous occur and may need general
anesthesia for reduction.

 Hypomobility:
Stiff joint or limitation of mouth opening

-classification of hypomobility diorders:

A. Trismus :
Stiffeness of masticatory muscles.
Causes of trismus:
 Myofunction pain dysfunction syndrome.
 Infection of periocronitis
 Tumor of jaw muscles.
 Fracture of mandibe.
 Tetanus “clostriduim tetani”
 Tetancy “hypo calcimia”.

B. False ankylsis:
Caused by extra articular factor of pathology and disappear after removed of
irritant factor.
Causes of false ankylosis :
 Malunion of zygmatic arch fracture.
 Fracture and dislocation of mandibular condyle.
 Adesion of coronoid process.
 Muscular fibrosis.
 Neurogenic closure as in epilypsy.
 Scleroderma.

C. True ankylosis :
Fibrous or bony fusion of intra articular joint structure.

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Causes:
 Trauma .
 Infection.
 Deliuary forceps.
 Inflammation.
 Tumor as osteo sarcoma of articular surface
 Complication of TMJ surgery or orthogenathic surgery.

D. Facial cellulitis.

 Treatment of internal derangement and it is phases:

 Conservative treatment :according to level
In myofacial pain dysfunction syndrome :
1.Psychological cause : refer to psychatric
Which treat the joint disorder indirectly “conterally” sedative and muscle
relaxant. By controlling the muscular spasm and there for reduce the muscular
pull of lateral ptregyoid muscle on disc and retro discal tissue.
2.Treatment of occlusion defect as:
a) Loss of posterior table from second premolar to third molar which
cause posterior collapse of the arch “unilaterally or bilaterally”.
b) Class III which usually associated with scissors bite and open bite.If
less than 1 cm can be treated without relapse.
c) Loss of teeth without replacement.
3. problem of muscle as :
Hypertrophy or hypotrophy, muscular decoordinated which may due to
psychological origin or neoplasm.

 Instruction for patient with MPD

1) Do not open the mouth so widely tearing of ligamint .
2) Selection of soft diet to avoid interfering with stabilization of disc position.

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3) Hot fomentation …relaxation of muscle .
4) Avoid chewing gum which cause tearing of ligament .
5) Avoid yowning and during this act press chin upward for stabilization of disc
in position .
6) Prescription of night guard which may be soft or hard in consistency with
thickness “2-3 mm” which cause separation between disc and condyle thus cause
decompression and stabilization of disc.
7) Prescription of analgesic .

 Surgical treatment :
If the patient do not follow the instruction precisly…the disc undergo more
displacement and more deterioration as tearing, perforation and herniation . and
condyle may articulate with posterior band or retrodiscal tissue which is the site
of innervation by auriculotemporal branch which supply capsule and retreodiscal
tissue thus pressure on retrodiscal tissue causing sever pain.

 Methods of surgical treatment :

1) Eminoplasty or Eminectomy :
Flatting of V-shap eminence by removal of 3-10mm maximally .
Main drow back of this method is;
Bone may be build up again which can be avoided by through cleaning and
creation of enough space followed post surgically by physiotherapy.

2) High condylar shave:

Removal of 2-5 mm of head of condyle this surgical method causing removal of
non-innervated dense fibro-cartilagenous tissue of articulating surface of TMJ
which result in early osteoastheritis .
 N:B… In case of disc tearing or perforation the condyle will articulate directly
to gelnoid fossa “bone to bone articulation”.

3) Disc plication:
There is plication of disc to retreodiscal tissue and capsule by creating V-shap cut
in redundant retrodiscal tissue and suturing the edges together.

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 N:B…“V-shap cut” To be easy sutured & sutures to be under tension.
 Meniscoraphy “meniscoplasty” :
But the patient in early stage post operativly may complaint from limited mouth
opening but it will become better by training because muscle pall of lateral
pterygoid muscle is stronger than plication.

4) Meniscetomy ‘surgical removal of dics’:

-In case of disc herniation, cracking or perforation
- In order to avoid bone to bone contact “articulation” the temporal foscia or
muscle may be used as inter-positioning material to facilate the movement and to
avoid osteo artheritis.
*the most convenince method is eminectomy with or without disc plication.

5) Zygomatic arch down fracture “dautrey operation”:

Increas hight of articular eminence by oblique orteotomy of arch.

Trauma
-It is the most common cause of condyle fracture.
- Trauma may be “direct or in direct”

 Direct trauma as :
trauma to mandibular left condyle cause :
-condylar fracture of ths side .
-this trauma transelated to right body .

 Indirect trauma “contralat fracture” :

Trauma in chin transelate to body and angle of the mandible …to condyle…to
cranial fossa …then return back to condyle because the condyle has thin and

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slender neck which act as “shock absorpant”absorpe the trauma which cause sub
condylar fracture and fractured condyle pulled by lateral pterygoid muscle
antero-medially.

 Type of condylar fracture:

1) Extra capsular or sub capsular or extra articular fracture and fractured
condyle move anteromedially ‘direction of muscle pull’.
2) Intra capsular or intra articular fracture.

Myofacial pain dysfunction syndrome

 Def :
Not disease in it is entity but there is dysfunction between articulation of
condyle, muscle of face and disc …or disharmony between disc movement and
condyle movement .

 Clinically “sign&symptoms”:
1) Pain with or without clicking .
Pain result from over excitation of muscular spasm “crump”as result of muscular
spasm there is production of lactic acid which is metabolic product causing
irritation to neuromasculer junction causing crump.
This pain can be relief bt “ethyle chlorid” temporary.
This hyper activity of muscle “superior head of lateral pterygoid muscle”affect the
delicate structure as disc retrediscal tissue causing loss of elasticity of retrodiscal
tissue ‘relaxation’ thus disc assume new pathologic position and hence the disc
become obstacle for movement instead of lubrication of movement.
Thus causing “reciprocal clicking” during closure and opening as a result of
imprisonment of disc between summite and condyle .
2) limited mouth opening :
Due to spasm of muscles.
3) changing habit of eating by selection of soft diet .

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 Etiology :
1) Psychological disturbance which cause deleterious effect on muscle.
2) Stress and tension.
3) Malocclusion as premature contact, loss of posterior occlusal table and loss of
centric relation and vertical diamension.
4) Bad habit as clenching, nail biting and bruxims.
5) Trauma to jaws while the mouth opening .
6) Tonsitectomy .
7) Excessive mouth opening while eating or yawing .
 Treatment :
1) Treatment of the cause :
a. Psychological cause …refer to psychatric.
b. Treatment for malocclusion.
2) Instruction for patient:
a. Do not open your mouth so widely causing tearing of ligament.
b. Selection of soft diet. To avoid interfering with stabilization of disc position.
c. Hot fomentation which cause relaxation of muscle .
d. Avoid chewing gum which cause tearing of ligament because the mandible
assume maximum protrusion position.
e. Avoid yawing as in case of yawing press or assist chin upward for stabilization
of disc in position.
3) prescripition of night guard.
4) Analgesic.

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