Surgical options for TMD Flashcards
11 possible TMJ diseases
* TMJ dysfunction (TMD Syndrome
* Jaw dislocation
* Osteo-arthritis
* Rheumatoid arthritis
* Chondromatosis
* Foreign body granuloma
* Infection
* Traumatic damage
* Radiation damage
* Ankylosis
* Tumours
Most common pain come across in practice related to TMJ – is TMD syndrome
* pain, clicking, crepitus – wide range of symptoms
TMD syndrome due to
2
excessive mechanial loading of TMJ joint
psycholoigical and trauma impact
TMD syndrome symptoms
pain
Pain may be:
A) muscular
B) capsular
C) intra-capsular ‘disc’
Reduced mobility
TMJ clicking and locking
crepitus
wide range
components of TMJ dysfunction
4
- Muscular “initiation”
- Mechanical “TMJ dysfunction”
- Psychological “underlying cause”
- Trauma “aetiology”
trauma of TMJ joint
2 types
macro trauma
micro trauma
macro trauma to TMJ
1 sudden incident of excessive direct mechanical trauma
E.g. long period open, hit
micro trauma to TMJ
Repetitive chronic overloading of TMJ
chronic joint overloading secondary to stress related repetitive clenching or Bruxism
* lateral pterygoid is inserted into the disc of TMJ – excessive spasm of this muscle, will affect the mechanical integrity of TMJ
Occlusal factors-
* a) deep bite
* b) occlusal disharmony eg. high filling
* c) lack of teeth
Anatomical factors
* Class II jaw relation
anatomical parts of TMJ
glenoid fossa (A) - bony cavity
condylar head (F)
articular disc (in between C and D (superior and inferior cavities) - each have own synovial membrane
lateral ligament
inner surface of capsule
articular disc
Fibrous extension of the capsule that runs between the two articular surfaces of the TMJ (mandibular fossa of temporal bone above and condyle of the mandible below)
Divides the joint into 2 sections each with their own Synovial Membrane
3 parts
* Anterior disc attaches to condyle and lateral pterygoid muscle (superior head) - Every time use muscle pull on disc
* Posterior part attached to mandibular fossa
- Retrodiscal tissue – highly innervated (pain) unlike rest of disc
* Bilateral zone of disc – made of collagen fibres part attached to posterior part of condyle and other part is posterior part of eminence - Brings back after lateral pterygoid pulls forward
Thin middle section – worry it will break, pathological issue (intermediate zone of TMJ)
lateral ligament
attaches the discs medially and laterally to condyle
capsule of TMj
fibrous membrane that surrounds the joint and attaches to the articular eminence, the articular disc and the neck of the mandibular condyle
origin of lateral pterygoid muscle
lateral surface of the lateral ptyergoid plate
how to palpate the lateral pterygoid
behind the maxillary tuberosity, couple of mm posteriorly
if sore on palpation have spasm of lateral pterygoid muscle - characteristic of excessive grinding etc
functional aspects of TMJ anatomy
Fibro-cartilage joint
* Function – at interfacing cartilaginous surfaces
Upper compartment – translation
Lower compartment – rotation
Cartilage, synovial fluid, joint shape, muscles and ligaments help to resist load
Alterations in any of the above or the teeth potentially alter joint loading
functional aspects of TMJ anatomy
Fibro-cartilage joint
* Function – at interfacing cartilaginous surfaces
Upper compartment – translation
Lower compartment – rotation
Cartilage, synovial fluid, joint shape, muscles and ligaments help to resist load
Alterations in any of the above or the teeth potentially alter joint loading
what can alter TMJ joint loading
Cartilage,
synovial fluid,
joint shape,
muscles
ligaments
teeth
upper compartment movement
translation
lower compartment movement
rotation
pt tells you there is a click and some grinding sensation around joint, sore and tender
what is happening
bilaminar zone still working to bring disc back
anteirorly located disc with reduction
when bilaminar zone stops bringing disc back after a few months
clicking progressed (been there months)
Disc becomes anteriorly located without reduction
Not able to bring back
* Pt cannot open mouth widely, clicking in joint, not much pain
* Disc is a mechanical obstacle
Need to address early to prevent this occurring
* Habit break
clicking happens/progresses in 2 phases
Pt tells you when open there is a click and some grinding sensation around joint, sore and tender
* Bilaminar zone still working to bring disc back
* anteriorly located with reduction
Bilaminar zone stops bringing disc after a few months (progress)
* Disc becomes anteriorly located without reduction
* Not able to bring back
* Pt cannot open mouth widely, clicking in joint, not much pain
* Disc is a mechanical obstacle
articular cartilage consists of
2
- chondrocytes
- collagen fibres in proteoglycan matrix
TMJ is fibro-cartilage joint
inflammatory disease affect on articular cartilage
produce proteases which degrade proteoglycans
innervated structures in TMJ
have pain
capsule
synovial tissue
subchondral bone
retrodiscal tissue
effect of compressive forces on TMJ
fibro-cartilage articular joint
can damage proteoglycans which protect collagen inflammation
produces proteases and hyalyronidase
synovitis of TMJ
chronic adhesive capsulitis & disc displacement
shearing forces affect on inflammed TMJ
due to previous compressive force
cause break up of collagen fibrils
cartilage degeneration process
3 stages
- chondromalacia
- collagen fibrillation
- subchondral bone exposure
degenerative changes that can occur in TMJ
6
- Cartilage degeneration
- Disc perforation
- Multiple adhesions & adhesive capsulitis
- Osteophytes
- Flattening of condyle & eminence
- subchodral cysts
conserative management of TMJ dysfunction
5 methods
Counselling
Pain management (analgesics)
* Don’t treat cause – treats the symptoms
Joint rest
* soft diet, support jaw, don’t over open, try and chew evenly
*
Physical therapy
Restoration of occlusal stability
functions of bite appliance
4
- Eliminates occlusal interferences
- Prevents the joint head from rotating so far posteriorly in the glenoid fossa
- Reduces loading on the TMJ
- Habit breaker – clenching and grinding
soft splint
functions of bite appliance
4
- Eliminates occlusal interferences
- Prevents the joint head from rotating so far posteriorly in the glenoid fossa
- Reduces loading on the TMJ
- Habit breaker – clenching and grinding
soft splint
possible invesigations for TMD
4
radiographs
arthrogram
MRI scan
arthroscopy
if disk is anteriorly dislocated without reduction….
tx options
need surgery
need radiograph to confirm
radiograph for TMD when
to confirm is disc is anteirorly dislocated without reduction
radiograph for TMD when
to confirm is disc is anteirorly dislocated without reduction
what is this
arthrogram of TMJ
Inject radio-opaque dye to see more detail
M is meniscus of disc
Cresent at top is superior and lower crescent is inferior compartment (material present here)
M should be at the top of condyle ( C ) but here it is at front – anterior disc location without reduction
what is this
MRI scan of TMJ (magnetic resonance imaging)
lateraly pteygoid is white part in front of black disc - anteriorly dislocated
arthroscopy of TMJ
Look inside the joint space via scope into superior compartment
Shape, inflammation, perforation, damage can be detected
Penetrate from front usually
- Can see synovial membrane and fluid – allow smooth movement
- See red coloration – inflammation due to excessive loading
arthroscopic procedures can help in:
6
- Diagnosis
- Biopsy
- Lysis (of fibrous adhesion) and lavage
- Disc reduction – release, cautery, suturing
- Removal of loose bodies
- Eminectomy (remove eminence to aid mouth opening if limited in anterior disc dislocation)
arthrocentesis
wash joint
* When conservative approach don’t work
* Increased lubrication and reduction of disc
Inject joint space (hyaluronic acid and some steroid) in superior compartment
Post op
* Rest, soft diet, bite raising appliance, pain management
intra and post op complications of TMD surgery/arthocentesis
- Iatrogenic suffering
- Broken instruments
- Middle ear perforation
- Glenoid fossa perforation
- Extravasation
- Haemorrhage
- Haemarthrosis
- Damage to CNV and CNVII
- Infection
- Disocclusion
- Laceration of EAM
- Perforation of tympanic membrane
TMD post op management
- Joint rest – soft diet, avoid widely opening
- Pain management
- Physical therapy
- Restoration of occlusal stability
likely still wear soft splint
TMD post op management
- Joint rest – soft diet, avoid widely opening
- Pain management
- Physical therapy
- Restoration of occlusal stability
likely still wear soft splint
8 possible surgical procedures of TMJ
- disc plication
- eminectomy
- high condylar shave
- condylotomy
- menscectomy
- condylectomy
- reconstructive procedures
- artrocentesis
disc plication
Normal conservative approach not work
Pre aurciuclar approach most common
- Cut through temporalis muscle and fascia
- Under zygomatic arch to see condylar process and eminence
- Grab the anterior dislocated disc and bring back and stitch in place using non resorbable stitch to temporalis muscle
eminectomy
remove eminence
reason for
* high condylar shave
* condylotomy
* condylectomy
remove mechanical obstruction for TMJ
meniscectomy
remove disc
4 indications for TMJ reconstructions
remove the whole joint and place a prosthesis
Joint destruction
* Trauma
* Infection
* Tumours
* Previous surgery
* Radiation
*
Ankylosis
Developmental deformity
Tumours – usually slow growing e.g.
* Giant cell lesions
* Fibro-osseous lesions
* Myxomas
*TMJ ankylosis more commmon in other parts – middle east, north Africa – need open and remove to allow rehab,
can have costochrondrograft or prosthesis via pre-auicular and inferior incision *
post op - pt who had pathology of TMj and replaced with prosthesis
ankylosis classification
4
Type I – Flattening deformity of condyle, little joint space & extensive fibrous adhesions.
TypeII – Bony fusion at outer edge of articular surface
TypeIII – Marked fusion bone between upper part of ramus of mandible & zygomatic arch.
TypeIV – Entire joint replaced by mass of bone
type I ankylosis
Type I – Flattening deformity of condyle, little joint space & extensive fibrous adhesions.
type II ankylosis
TypeII – Bony fusion at outer edge of articular surface
type III ankylosis
TypeIII – Marked fusion bone between upper part of ramus of mandible & zygomatic arch.
type IV ankylosis
TypeIV – Entire joint replaced by mass of bone
what to be careful of in TMJ recon surgery
Careful of facial nerve – go under fascia to go to zygomatic arch
Cut zygomatic arch and expose condyle completely
ID fossa and eminence
Remove osteochondroma tumour and affected condyle
