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
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)
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
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
