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Internal Derangement Disorders (Temporomandibular Joint)

The most frequent structural (as opposed to muscular) causes of temporomandibular joint dysfunction (TMD) are internal derangements, which involve progressive slipping or displacement of a component of the temporomandibular joint called the articular disc. The disc is a piece of cartilage located between the condyle ("ball") and fossa ("socket") of the joint. It supports the bones in the joint, preventing them from rubbing together and allows the joint to move smoothly. If the disc slips out of place or is displaced, it can prevent the proper movement of the condyle and cause dysfunction. The disc can degenerate, becoming misshapen or even torn. Because the deranged joint will continue to try to function, even in an impaired manner, internal derangement disorders often get progressively worse with time.

Tearing or stretching of the ligaments holding the disc in place often causes an internal derangement. The condition can be caused by an acute trauma, such as a blow to the face. It may also be caused by more chronic, micro-trauma, wear on the joint, such as from bruxism, a very bad bite (severe malocclusion) or repeated excessive jaw movements.

Internal derangements can be either or both soft-tissue or bony. There are two basic types of soft-tissue internal derangements. The more common is referred to as an internal derangement with reduction; the disc slides into and out of its normal functional position as the jaw opens or closes, causing the popping sound characteristic of TMD. In cases of internal derangement without reduction, the disc is permanently displaced or dislocated to an incorrect position, and the jaw's range of motion is limited.

Symptoms

Like other forms of TMD, internal derangement disorders can cause a wide range of pain symptoms. Symptoms often involve pain in the jaw joints, especially associated with jaw movements. Dull aching, stabbing, or burning pain may also be felt in the surrounding muscles of the face. This pain can occasionally refer elsewhere, potentially leading to pain throughout the head and in the neck and shoulders. Earaches, tinnitis (ringing in the ear), or even the feeling of reduced hearing can sometimes occur.

Loud and/or painful clicking or popping sounds when opening or closing the jaw often characterizes internal derangement disorders. Patients may have a limited range of jaw opening, and/or will periodically or permanently feel that the jaw is locked.

Diagnosis

Imaging techniques such as X-ray, CT or MRI scans, and arthroscopy are used to determine whether there is a structural problem at the TMJ.

Treatment

In early stages of the condition, treatment may involve eating a soft diet and reducing strain on the jaw with the use of a splint or bite guard. Non-steroidal anti-inflammatory drugs or muscle relaxants may be prescribed. Physical therapy and stress management may also be helpful in managing the condition. If the derangement becomes more severe or refractory (unresponsive) to conservative and non-surgical treatment, it may be necessary to surgically repair, reposition, or possibly remove and consider replacing, the disc and/or bony joint.

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