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Internal Derangement of TMJ,ankylosis, Flashcards

1
Q

define internal derangement of TMJ

A

disorder of TMJ in which articular disk is in an abnormal position as it relates to the condyle and fossa when the teeth are in occlusion.

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2
Q

what can malposition of the articular disk lead to? (4)

A

-pain
-instability
-dec range of motion
-abnormal mobility of mandible

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3
Q

6 etiologies of internal derangement of TMJ

A

-trauma
-joint laxity
-parafunctional habits
-altered joint lubrication system
-anchored disk phenomenon (disk adhesion to articular fossa)
-myofascial pain dysfunction

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4
Q

-dec max incisal opening
-deviation
-deflection
-palpable clicks (reciprocal)
-crepitus
-patients complain of pain in preauricular region

A

internal derangement of the TMJ

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5
Q

Imaging dx for internal derangemeent of TMJ

A

MRI-T1 and T2. Disk is normally displaced in an anteriomedial vector
-osseous changes
-abnormal contours of disk

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5
Q

disk displacement w/o reduction

A

patient attempts to open but condyle can’t pass over posterior band of disk.

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6
Q

what do you see with disk displacement w/o reduction

A

deflection to the ipsilateral side
decreased excursion to contralateral side

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6
Q

what is disk displacement w/ reduction when patient opens what happens?

A

patient opens mouth w/ click that is produced when condyle passes over posterior part of disk
-during opening the disk returns to normal anatomical position
-during closing , a second click can be appreciated as the condyle passes back over the thickened posterior portion of the disk.

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7
Q

what classification classifies the degree of internal derangement and provides guidance in treatment options?

A

Wilkes classification
stage I-V

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8
Q

Wilkes stage 1 radiographic findings

A

anterior disk displacement
normal disk contour, no osseous changes

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8
Q

Wilkes stage 1 clinical findings

A

painless clicking
no pain
no locking

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9
Q

Wilkes stage 1 surgical findings

A

normal disk noted and displaced anteromedially

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10
Q

Wilkes stage II clinical findings

A

occasional painful clicking with intermittent locking

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11
Q

wilkes stage II radiographic findings

A

anterior disk displacement w/reduction on opening
mild disk deformity w/ no osseous changes

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12
Q

wilkes stage II surgical findings

A

disk thickened and displaced anteriormedially

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13
Q

wilkes stage III clinical findings

A

-frequent painful clicking w/ severe limitation in range of motion
-joint tenderness

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14
Q

wilkes stage III radiographic findings

A

anterior disk displacement w/o reduction
moderate disk deformity
no osseous changes

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15
Q

wilkes stage III surgical findings

A

deformed disk and displaced anteromedially
-adhesions may be appreciated

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16
Q

wilkes stage IV clinical findings

A

-restricted range of motion with chronic pain and joint crepitus

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17
Q

wilkes stage IV radiographic findings

A

anterior disk displacement w/o reduction
marked disk deformity w/ osseous changes

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18
Q

wilkes stage IV surgical findings

A

disk perforated w/ osseous changings of the condylar head and fossa

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19
Q

wilkes stage V clinical findings

A

joint pain and crepitus

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20
Q

wilkes stage V radiographic findings

A

disk displaced
marked disk deformity w/ severe osseous changes

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21
Q

wilkes stage V surgical findings

A

disk perforated w/ severe osseous changes of the condylar head and fossa.

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22
6 tx of internal derangement of TMJ
-conservative tx -intra-articular injections w/ local anesthetic/steroid mixture -arthrocentesis w/ or w/o arthroscopy w/ repositioning -meniscectomy w/ or w/o graft replacement -modified condylectomoy -post op physical therapy
23
2 classification systems of ankylosis
Sawhney Type 1-4 Topazian stage 1-3
24
Topazian stages
stage 1-only condyle stage 2-extends to sigmoid notch stage 3-entire condyle,sigmoid notch and coronoid
25
sawhney type 1 and type 2
type 1-flattned condylar head w/ close approximation to joint space type 2-flattened condyle close to glenoid fossa,bony fusion on outer surface of articular surface. No fusion of medial joint space
26
sawhney type 3 and 4
type 3-bony block bridging the mandibular ramus and zygomatic arch type4-wider boney block bridges the mandibular ramus and zygomatic arch, completely replacing architecture of joint
27
adult tx of tmj ankylosis
prosthetic joint
28
pediatric tx of tmj ankylosis
7 step KABAN protocol
29
7 step Kaban protocol
1.aggressive resection of fibrous/bony ankylotic mass 2.coronoidectomy on affected side and measure intra op MIO 3.coronoidectomy on contralateral side if can't achieve MIO>35 mm and/or to the point of dislocation of the unaffected TMJ 4.Lining of the TMJ w/ temporalis myofascial flap or disk if salvageable 5.reconstruction of ramus condyle unit 6.early mobilization of jaw 7.aggressive physiotherapy
30
2 ways to reconstruct ramus condyle unit
-distraction osteogenesis -costochondral graft
31
reconstruction of ramus condyle unit with distraction osteogenesis, when do you activate? when do you mobilize?
activate in 2-4 days mobilize day of operation
32
reconstruction of ramus condyle unit with costochondral graft, how long do you put in maxillary-mandibular fixation? when do you mobilize?
10 days IMF mobilize after 10 days of IMF
33
what takes advantage of the fibrocartilaginous cap that forms on the advancing front of the distracted bone heading toward the fossa
distraction osteogenesis
34
2 tx for fibrous ankylosis
-lysis of adhesions and fibrosis -diskectomy
35
post op radiation tx for ankylosis
radiation therapy, 20 Gray in 10 fractions to prevent recurrence and consider when using autogenous grafting as the risk of recurrence is higher
36
how much rib can be harvested from child
7-10 cm
37
how much rib can be harvested from adult
12-17 cm
38
which ribs can be harvested and why
ribs 4-7 bc they have direct cartilaginous connection to the strernum.
39
what rib is mostly harvested and why?
rib 6, as incision falls in the inframmamary crease creating a better cosmetic outcome
40
which side of rib to harvest?
right side- less confusion w/ cardiogenic pain -contralateral to side of defect to allow appropriate curvature.
41
rib harvest, describe incision
sharp incision inframammary crease 5 cm long
42
dissection of rib harvest is
subcutaneous tissue fascia plane btwn pec major and rectus abdominis
43
what is used to straddle the 5th & 6th intercostal space
2 fingers
44
after dissection of subq tissue fascia plane btwn pec major and recutus abdominis what is then done?
sharp incision cut through periosteum down to the outer cortex of the rib -molt periosteal to dissect in subperiosteal plane
45
what is doyen rib stripper associated with
pleural tears
46
after you get to subperiosteal plan what do you do?
sharp blade to make the cartilagious incision then pull rib laterally and protected rib cutter to section rib
47
why is it impt to not harvest more than 3 cm , no less than 1 cm in children
avoid overgrowth of the rib and to prevent seperation of the cartilaginous cap
48
how to check for pleural tears during rib harvest?
fill cavity with normal saline and have anesthesia perform valsava to check for bubbles
49
what do you close periosteal sleeve during rib harvest and why
3-0 polygalactin, may promote denovo regeneration of the missing rib in the child
50
fascia btwn rectus and pec major is closed with
3-0 resorbable suture then close subq and skin.
51
why do you get post op chest x ray after rib harvest?
rule out pneumothroax rule out hemothorax
52
after rib harvest when can patient return to normal activity
7 days, strenous activity in 6 weeks.
53
3 complications of rib harvest
-cartilaginous cap seperated from harvested rib -pneumothorax -pleural tear
54
txcartilaginous cap seperated from harvested rib
-drill hole through width or rib and tie nonresorable suture to secure cap -harvest second rib above, rib directly above is preserved to prevent cosmetic defect.
55
tx -pneumothorax
-10% or less in size can be left to resorb with serial xrays -100% pneumothorax required needle decompression by placing iv catheter at 2nd intercostal space along mid-clavicular line and listen for rush of air -tube thoracostomy
56
tx -pleural tear
suction cathether placed in wound, purse string suture through the tear, suction catheter removed under suction while tighteningt he purse string simultaneously
57
tube thoracostomy incision
2-3 cm incision at 5th intercostal space -proximal end of thoracotomy tube is clamped and advanced over 6th rib avoiding neurovascular bundle on inferior border of 5th rib -tube is placed to water-sealed suction drainage
58
what is it called when condylar head is anterior to the articular eminence causing open lock
hypermobility/dislocation/mandibular subluxation resulting in an inability to close from patient's max incisal open position
59
2 acute tx for dislocation
bimanual mandibular manipulation in a downward and posterior vector wrap head with barton bandadge for a week to allow stretched tissues to heal
60
5 chronic tx for dislocation
intra articular injection of sclerosing agent-alcohol or autogenous blood -botox in lateral pterygoid -LeClerc/Dautrey procedures-zygomatic arch osteotomites -eminectomy -lengthening articular eminence w/ bone graft from calvarium,symphysis,ramus.

TMJ (10 decks)

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