Surgical Options in TMD Flashcards
What is difference between anterior disc displacement with reduction and anterior disc displacement without reduction?
Disc is anteriorly displaced and reduced on opening.
- As the patient opens, the disc is anterior to the condylar head, anteriorly displaced and causes stretch of the bilaminar zone. As the patient closes their mouth, the bulaminar zone will eventually pull the disc back in between the condylar head and the glenoid fossa- the disc will move backwards (causing a click) and the condyle will move back as well.
- Jaw tightness/locking until the disc reduces and mandible may initially deviate to the affected side before returning to the midline.
Disc is consistently lying anterior to the condyle during all mandibular movements because the bilaminar zone has been stretched too far during displacement of the disc and the disc cannot be put back into the joint cavity. This results in the patient having limited mouth opening and unable to close their mouth “locked jaw”.
What aspects of the examination is important in someone with suspected TMD?
Assymetry- condylar hyperplasia may be causing this
Swellings.
Palpate the TMJ- 2 fingers the left and right side of the TMJ, just anterior to the tragus of the ear.
- Do you have any tenderness when I press here?
- Ask them to open and close and listen for any noises.
- Any deviations to the left or right on opening or closing?
- Move their jaw forwards and backwards.
MOM exam-
- Temporalis
- Masseter- check extra-orally and intra-orally.
- Cannot reliably palpate the ptergyoids.
- Ask if they have pain anywhere here when you do this.
Measure mouth opening
- Can use a roller, Willis bite gauge, wooden sticks.
- 35-45mm is normal, less than 35mm is heading towards trismus.
Intra-oral
- scalloping of the tongue
- Linea Alba
- Toothwear
- Cheek biting
What results from an examination would suggest a muscle issue?
Tender on palpation and tender when clenching.
What results from an examination would suggest a disc issue?
Clicking on closure.
What results would suggest a degenerative joint issue?
Crepitus on movement of the TMJ.
What are the components of TMJ dysfunction?
Muscular problems- inflammation of MOM or TMJ secondary to parafunctionla habit.
Mechanical problems- with the TMJ itself.
Psychological- stress is causing bruxism and clenching
Trauma- macrotrauma, microtrauma, occlusal factors, anatomical factors (class 2 div 1).
What signs and symptoms might someone present with?
Intermittent pain of several months or years of duration
Muscle/joint/ear pain, particularly on wakening
Trismus/locking of the jaw
Clicking/popping joint noises or crepitus
Headaches
What aspects of the history taking process would you want to ascertain from someone with suspected TMD?
SOCRATES
SH is very important- occupation, stress, home circumstances, sleeping pattern, recent bereavement, relationships, habits, hobbies
What are the potential causes of TMD?
Myofascial pain
Disc displacement with or without reduction
Degenerative diseases- osteoarthritis, rheumatoid arthritis
Chronic recurrent dislocation
Ankylosis
Condylar hyperplasia
Neoplasia
Infection
Describe the anatomical features of the TMJ?
Glenoid fossa
Condylar head
Articular disc
Lateral ligament
Internal surface of the capsule
Synovial membrane
How might inflammatory disease with the TMJ affect it?
Inflammatory disease produces proteases which degrade proteoglycans.
Proteoglycans are a key component in articular cartilage.
What nerve innervates the TMJ?
Auriculotemporal nerve posteriorly and masseteric nerve anteriorly.
Why might pain specifically in the TMJ manifest itself?
Compressive forces may damage proteoglycans present within articular cartilage.
Inflammation produces protease and hyaluronidase.
What conservative management is indicated for TMD?
Counselling- soft diet, masticate bilaterally, no wide opening, no chewing gum, don’t incise food, cut food into small pieces, stop nail biting/grinding, support mouth on opening, reduce caffeine intake.
Advise on pain relief- ibuprofen, paracetamol.
Jaw exercises- physiotherapy.
Massage/heat.
Ultrasound therapy
TENS
Bite raising appliances- soft acrylic splint, Michigan splint, hard acrylic bit raising appliance,
- stabilise the occlusion and improve function of the masticatory muscle, thereby decreasing abnormal activity. Also protect the teeth in case of tooth grinding.
Restoration of occlusal instability- high restorations.
When should you refer a patient for their TMJ pain?
Severe trismus
Non-responsive to conservative management
History of trauma in the area
