Chapter 379

Temporomandibular joint (TMJ) disorders in children are relatively rare. They can be divided into extra-articular and intra-articular types, which can occur alone or together.

The most common TMJ problem is myofascial pain, which is extra-articular in origin. The muscles of mastication can have a high resting tone, and they are often in spasm because of muscle hyperfunction or parafunction due to daytime and nocturnal jaw clenching (bruxism). Myofascial pain is more common in the morning and is often associated with a decrease in function. Related symptoms include headache, ear pain, joint noises, closed or open lock, difficulty chewing, and limited mouth opening.1

Intra-articular TMJ disorders that result from an abnormal relationship between the condyle and mandibular disk are also often associated with symptoms of myofascial pain.2 Spasm of the lateral pterygoid muscle, which inserts into the disk, can displace the disk anterior to the condyle.3 Anterior displacement with reduction occurs when the condyle moves under the displaced disk into a normal relationship and the opening movement occurs without impediment. This is usually associated with a midopening click, which can be audible and/or palpable. Anterior displacement without reduction is often the result of adverse loading of the TMJ or sudden trauma to the joint. When there is tearing and scarring of the retrodiscal tissues, the displacement is likely to be permanent and results in the disk losing its shape and becoming rounder, blocking the condyle from normal movement. When this occurs, the patient can only rotate, which limits opening to the 25-mm range.

### Treatment

Treatment of myofascial pain is focused on diminishing muscle hyperactivity. The goals of therapy include eliminating behavior that is noxious to the muscles and joints; decreasing the frequency, duration, and intensity of pain episodes; providing support and counseling about stress reduction and other psychologic concerns; and establishing a functional and adequate jaw opening. Nonsurgical management is used to treat myofascial pain, and most patients respond well to this treatment.

Some of the nonsurgical treatment modalities include a soft diet with elimination of hard/chewy foods, thereby reducing the loading forces on the joint and decreasing muscle activity. Physical therapy to increase range of joint motion and muscle relaxation, massage of the muscles of mastication, and cold or hot compresses applied before and after exercises may also be helpful.4,5 Ultrasound can deliver heat to a depth of about 5 cm, and when done in combination with stretching, it can alter the elastic properties of connective tissue.6

Splint therapy with the use of a flat plane acrylic appliance that fits onto the dentition and disoccludes the teeth and jaws diminishes the loading forces on the discal tissue. Additionally, the splint distracts the condyle slightly out of the fossa and reduces pressure on the intracapsular tissues. Interrupting the normal proprioception of the masticatory system reduces muscle activity.7,8 Splints are ...

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