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BDS4 CDS Oral Surgery > Surgical options for TMD > Flashcards

Surgical options for TMD Flashcards

1
Q

11 possible TMJ diseases

A

* 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

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2
Q

TMD syndrome due to

2

A

excessive mechanial loading of TMJ joint

psycholoigical and trauma impact

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3
Q

TMD syndrome symptoms

A

pain

Pain may be:
A) muscular
B) capsular
C) intra-capsular ‘disc’

Reduced mobility

TMJ clicking and locking

crepitus

wide range

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4
Q

components of TMJ dysfunction

4

A
  • Muscular “initiation”
  • Mechanical “TMJ dysfunction”
  • Psychological “underlying cause”
  • Trauma “aetiology”
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5
Q

trauma of TMJ joint
2 types

A

macro trauma

micro trauma

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6
Q

macro trauma to TMJ

A

1 sudden incident of excessive direct mechanical trauma

E.g. long period open, hit

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7
Q

micro trauma to TMJ

A

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

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8
Q

anatomical parts of TMJ

A

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

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9
Q

articular disc

A

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)

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10
Q

lateral ligament

A

attaches the discs medially and laterally to condyle

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11
Q

capsule of TMj

A

fibrous membrane that surrounds the joint and attaches to the articular eminence, the articular disc and the neck of the mandibular condyle

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12
Q

origin of lateral pterygoid muscle

A

lateral surface of the lateral ptyergoid plate

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13
Q

how to palpate the lateral pterygoid

A

behind the maxillary tuberosity, couple of mm posteriorly

if sore on palpation have spasm of lateral pterygoid muscle - characteristic of excessive grinding etc

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14
Q

functional aspects of TMJ anatomy

A

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

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14
Q

functional aspects of TMJ anatomy

A

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

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15
Q

what can alter TMJ joint loading

A

Cartilage,
synovial fluid,
joint shape,
muscles
ligaments
teeth

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16
Q

upper compartment movement

A

translation

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17
Q

lower compartment movement

A

rotation

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18
Q

pt tells you there is a click and some grinding sensation around joint, sore and tender

what is happening

A

bilaminar zone still working to bring disc back

anteirorly located disc with reduction

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19
Q

when bilaminar zone stops bringing disc back after a few months

clicking progressed (been there months)

A

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

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20
Q

clicking happens/progresses in 2 phases

A

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

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21
Q

articular cartilage consists of

2

A
  • chondrocytes
  • collagen fibres in proteoglycan matrix

TMJ is fibro-cartilage joint

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22
Q

inflammatory disease affect on articular cartilage

A

produce proteases which degrade proteoglycans

23
Q

innervated structures in TMJ

have pain

A

capsule
synovial tissue
subchondral bone
retrodiscal tissue

24
effect of compressive forces on TMJ | fibro-cartilage articular joint
can damage proteoglycans which protect collagen inflammation produces proteases and hyalyronidase
25
synovitis of TMJ
chronic adhesive capsulitis & disc displacement
26
shearing forces affect on inflammed TMJ | due to previous compressive force
cause break up of collagen fibrils
27
cartilage degeneration process | 3 stages
* chondromalacia * collagen fibrillation * subchondral bone exposure
28
degenerative changes that can occur in TMJ | 6
* Cartilage degeneration * Disc perforation * Multiple adhesions & adhesive capsulitis * Osteophytes * Flattening of condyle & eminence * subchodral cysts
29
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
30
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
31
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
32
possible invesigations for TMD | 4
radiographs arthrogram MRI scan arthroscopy
33
if disk is anteriorly dislocated without reduction.... tx options
need surgery need radiograph to confirm
34
radiograph for TMD when
to confirm is disc is anteirorly dislocated without reduction
35
radiograph for TMD when
to confirm is disc is anteirorly dislocated without reduction
36
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
37
what is this
MRI scan of TMJ (magnetic resonance imaging) lateraly pteygoid is white part in front of black disc - anteriorly dislocated
38
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
39
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)
40
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
41
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
42
TMD post op management
* Joint rest – soft diet, avoid widely opening * Pain management * Physical therapy * Restoration of occlusal stability | likely still wear soft splint
43
TMD post op management
* Joint rest – soft diet, avoid widely opening * Pain management * Physical therapy * Restoration of occlusal stability | likely still wear soft splint
44
8 possible surgical procedures of TMJ
* disc plication * eminectomy * high condylar shave * condylotomy * menscectomy * condylectomy * reconstructive procedures * artrocentesis
45
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
46
eminectomy
remove eminence
47
reason for * high condylar shave * condylotomy * condylectomy
remove mechanical obstruction for TMJ
48
meniscectomy
remove disc
49
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
50
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
51
type I ankylosis
Type I – Flattening deformity of condyle, **little joint space** & extensive fibrous adhesions.
52
type II ankylosis
TypeII – Bony fusion at **outer edge** of articular surface
53
type III ankylosis
TypeIII – **Marked fusion** bone between upper part of ramus of mandible & zygomatic arch.
54
type IV ankylosis
TypeIV – Entire joint replaced by **mass** of bone
55
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

BDS4 CDS Oral Surgery (19 decks)

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