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BDS4 Oral Surgery > Temporomandibular Joint > Flashcards

Temporomandibular Joint Flashcards

1
Q

What bones are involved in the temporomandibular joint?

A
  • temporal bone
  • sphenoid bone
  • zygomatic bone
  • maxilla
  • mandible
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2
Q

What are the two superior processes of the mandible called?

A
  • condyle/condylar process
  • coronoid process
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3
Q

What is found between the condyle and the coronoid process?

A

mandibular notch

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4
Q

Where does the mental nerve exit the mandible and what does it supply?

A

the mental nerve exits the mandible through the mental foramen and supplies the chin and some of the lower anterior teeth

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5
Q

Where is the mandibular foramen located and what enters into it?

A
  • the internal aspect of the mandible
  • inferior alveolar nerve
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6
Q

Where is the submandibular fossa located and what does it facilitate?

A
  • the internal aspect of the mandible
  • submandibular salivary gland
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7
Q

At what points do the mandible and temporal bone articular?

A
  • condylar process of mandible
  • mandibular fossa of temporal bone
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8
Q

What part of the zygomatic arch limits anterior movement of the condyle?

A
  • articular tubercle/eminence
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9
Q

What structures are located posterior to the temporomandibular joint?

A
  • external auditory meatus
  • mastoid process
  • styloid process
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10
Q

What kind of joint is the temporomandibular joint?

A

synovial joint at the articulation between the condylar process of the mandible and mandibular fossa of the temporal bone at the region of the infratemporal fossa

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11
Q

What component splits the temporomandibular joint into an upper and lower compartment?

A
  • articular disc
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12
Q

What movements are permitted in the upper compartment of the temporomandibular joint?

A
  • gliding
    • protrusion
    • retraction
  • side to side
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13
Q

What movements are permitted in the lower compartment of the temporomandibular joint?

A
  • rotational
    • elevation
    • depression
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14
Q

When can depression of the mandible occur?

A
  • when the condylar process has moved anteriorly within the upper compartment of the joint
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15
Q

When does the temporomandibular joint become dislocated?

A

When the condyle moves anterior to the articular eminence

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16
Q

What supports the temporomandibular joint?

A
  • joint capsule
  • extracapsular ligament
    • lateral temporomandibular ligament
    • sphenomandibular ligament
    • stylomandibular ligament
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17
Q

Where does the lateral temporomandibular ligament attach?

A
  • zygomatic arch
  • posterior portion of neck of the mandible
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18
Q

What is the function of the lateral temporomandibular ligament?

A
  • to limit posterior movement of the mandible
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19
Q

What is the function of the sphenomandibular ligament and stylomandibular ligament?

A
  • to limit lateral movement of the mandible
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20
Q

Where does the sphenomandibular ligament attach?

A
  • the internal aspect of the ramus of the mandible
  • sphenoid bone
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21
Q

Where does the stylomandibular process attach?

A
  • internal aspect of the ramus of the mandible
  • styloid process
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22
Q

Where are the pterygoid muscles located?

A
  • medial to the mandible
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23
Q

Describe the medial pterygoid

A
  • two heads
    • deep head
    • superficial head
    • run posteriorly-inferiorly and fuse
  • deep head attached to the medial aspect of the lateral pterygoid plate
  • superficial head attached to the maxilla and the palatine bones
  • fused muscle attached to internal aspect of ramus of the mandible
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24
Q

Describe the lateral pterygoid

A
  • 2 heads
    • superior head
    • inferior head
  • superior head
    • attached to roof of infratemporal fossa and lateral portion of lateral pterygoid plate
  • inferior head
    • attached to lateral portion of lateral pterygoid plate
  • heads fuse and attach to the condylar process
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25
Q

What is the function of the lateral pterygoids?

A
  • when acting bilaterally
    • protrusion
  • when acting unilaterally
    • swing to contralateral side
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26
Q

What is the function of the medial pterygoid?

A
  • when acting bilaterally
    • elevation (closing jaw)
    • aid protrusion
  • when acting unilaterally
    • swing jaw to contralateral side
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27
Q

Describe the temporals muscle

A
  • fan shaped
    • anterior vertical fibres
    • posterior horizontal fibres
  • arises from temporal fossa
  • attaches to coronoid process of mandible
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28
Q

What is the function of the temporalis?

A
  • anterior vertical fibres
    • elevating the mandible (closing)
  • posterior horizontal fibres
    • retract the mandible
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29
Q

Where is the masseter located?

A

the lateral side of the mandible

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30
Q

Describe the masseter

A
  • 2 heads
    • superficial head
    • deep head
  • the superficial head attaches to the zygomatic bone
  • the deep head attaches to the zygomatic arch
  • both heads slant inferiorly to attach to the ramus and angle of the mandible
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31
Q

What is the function of the masseter?

A
  • elevates the mandible (closes)
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32
Q

When is the temporomandibular joint most stable?

A

when the teeth are in occlusion

33
Q

What is the most common type of displacement of the temporomandibular joint?

A

anterior dislocation

34
Q

What opposes anterior dislocation of the temporomandibular joint?

A
  • articular eminence
  • lateral ligament
  • contraction of medial pterygoid, masseter and temporalis
35
Q

Describe anterior dislocation of the temporomandibular joint

A
  • the condyle moves anterior to the articular eminence
  • muscles of mastication spasm
  • mandible cannot retract
36
Q

How is anterior dislocation of the temporomandibular joint managed?

A
  • application of downwards pressure on the lower molars
  • guiding condyle back into mandibular fossa
37
Q

How should examination of the temporomandibular joint examination be carried out?

A
  • place 2 fingers over the right and left temporomandibular joints, just anterior to the tragus of the ear
  • palpate the joints and ask the patient if there is any pain or tenderness
  • ask the patient to open and close slowly and listen and feel for clicks or crepitus
  • observe for any deviations of the mandible left or right
  • ask the patient to protrude and move their mandible side to side, looking for and deviations or restrictions
38
Q

How should the muscles of mastication be examined?

A
  • temporalis
    • ask patient to clench
    • palpate posterior, mid and anterior aspects
    • note any tenderness or pain on palpation
  • masseter
    • bimanual palpation is most reliable
    • ask patient to clench
    • palpate inferior, mid and superior aspects
    • note any tenderness or pain on palpation
39
Q

How should mouth opening be examined?

A
  • using inter-incisal distance
    • use fingers as a rough guide
    • around 14mm is average
40
Q

What signs intra-orally can indicate a clenching/grinding habit?

A
  • scalloping of the tongue
  • scalloping of the buccal mucosa
  • presence of lines alba
  • attrition
41
Q

What conservative advice can be given for temporomandibular joint pain?

A
  • results can take a couple of weeks to a few months to show
  • describe the clenching habit
    • times which clenching happens
      • driving
      • working at a computer
      • gym
  • splint
    • usually soft lower splint
  • relaxation and de-stressing
    • yoga
    • meditation
    • breathing exercises
  • reduce caffeine intake
  • ibuprofen
    • on flare up of symptoms
  • hot and cold packs
    • alternate
    • if one provides better results, use that
  • soft diet
    • reduced forces
    • reduced mouth opening
  • exercises
    • physiotherapy in some cases
42
Q

What other names can temporomandibular joint dysfunction be called?

A
  • myofascial pain dysfunction
  • pain dysfunction syndrome
  • facial arthromyalgia
  • Cosine’s syndrome
  • TMJ
43
Q

Why is temporomandibular dysfunction often confused with ear ache/infection?

A

the auriculotemporal nerve which supplies some innervation to the TMJ also provides sensation to parts of the external auditory meatus and patients can find it difficult to distinguish the source of the pain

44
Q

What is the blood supply of the temporomandibular joint?

A
  • deep auricular artery
    • branch of maxillary artery (first part)
45
Q

What is the nerve supply of the temporomandibular joint?

A
  • auriculotemporal
  • masseteric
  • posterior (deep temporal nerve)
46
Q

What are the accessory muscles of mastication and what two categories are they split into?

A
  • suprahyoid
    • digastric
    • mylohyoid
    • geniohyoid
    • stylohyoid
  • infrahyoid
    • thyrohyoid
    • sternohyoid
    • omohyoid
    • sternothyroid
47
Q

What parts of the articular disc causes pain and why?

A
  • the anterior band is not innervated so does not cause pain
  • the area between the posterior band and bilaminer zone is innervated
  • the bilaminer some is most richly innervated and vascularised
    • this area reports pain
    • usually when compressed by the condyle
48
Q

What are the causes of temporomandibular dysfunction?

A
  • myofascial pain
    • related to muscles and fascia associated with the joint
    • most common cause
  • disc displacement
    • also relatively common
    • anterior with reduction
    • anterior without reduction
  • degenerative disease
    • localised
      • osteoarthritis
    • generalised/systemic
      • rheumatoid arthritis
  • chronic recurrent dislocation
    • recurrent dislocation of the temporomandubular joint
    • condyle is stuck in front of the articular eminence and mouth is stuck open
  • ankylosis
    • pure ankylosis is very rare
      • condyle fused to base of skull
    • usually pyseudoankylosis
      • often genetic
  • hyperplasia
    • one condyle grows more than the other
    • results in facial asymmetry
      • jaw points contralateral direction to hyperplastic condyle
    • usually requires surgery
  • neoplasia
    • rare to have tumours in the temporomandibular joint
      • usually affects surrounding structures
    • osteochondroma
      • affects cartilage
    • osteoma
      • benign bone tumour
    • osteosarcoma
      • malignant bone tumour
  • infection
    • primary infection of the joint is very rare
    • can result in ankylosis
49
Q

Describe anterior disc displacement with reduction

A

the articular disc displaces more anteriorly than it should in the joint, the disc is able to slip back into its correct position in the joint

50
Q

Describe anterior disc displacement without reduction

A

the articular disc displaces more anteriorly than it should outwit the joint, the disc is unable to slip back into its correct position in the joint and becomes stuck in front of the condyle

51
Q

How is chronic recurrent dislocation of the temporomandibular joint managed?

A
  • the first occurrence is often very distressing
  • over time patient gets used to it and is able to manage it themselves
  • mandible must be manipulated back into place
  • if patient presents to GDP, have patient sitting upright and place thumbs in the buccal sulcus on each side, press downwards and backwards
  • sometimes muscle relaxants are required
52
Q

Describe the pathogenesis of temporomandibular dysfunction

A
  • inflammation of muscles of mastication of TMJ secondary to parafunctional habits
  • trauma
    • directly to the joint
    • indirectly
    • single episode
    • multiple episodes over time
  • stress
    • more tense
    • more likely to clench teeth
  • psychogenic
  • occlusal abnormalities
    • no evidence
    • significantly high contact may cause muscle pain due to abnormal posturing of the mandible
53
Q

What should a pain history involve for a patient presenting with temporomandibular dysfunction?

A
  • location
  • nature
  • duration
  • exacerbating/relieving factors
  • frequency
  • time of occurrence
    • morning indicates bruxism
    • during the day indicates habits
  • associated pain
    • neck
    • shoulders
54
Q

What should a social history involve for a patient presenting with temporomandibular dysfunction?

A
  • occupation
  • stress
  • home circumstances
  • sleeping pattern
  • recent bereavement
  • relationships
  • habits
  • hobbies
    • any activity requiring the teeth to be brought together other than eating will worsen the condition
55
Q

What should be observed during an extraoral examination and what may be present for a patient with temporomandibular dysfunction?

A
  • muscles of mastication
    • palpation of masseter and temporalis may be tender or painful
    • medial pterygoid is uncomfortable to palpate
    • lateral pterygoid is not palpable
      • painful and would induce gagging
  • temporomandibular joint
    • clicks
      • early or late
    • crepitus
      • indicates arthritic change
      • crunching sound
  • jaw movements
    - limited movement
    - deviations
  • facial asymmetry
56
Q

What should be observed during an intraoral examination and what may be present for a patient with temporomandibular dysfunction?

A
  • interincisal mouth opening
    • use a Willis bite gauge
    • use measurement as a baseline
  • cheek biting
    • morsicato buccarum
  • linea alba
    • white line present on buccal mucosa
  • tongue scalloping
    • due to tongue thrusting on clenching
  • occlusal non-carious tooth surface loss
    • tooth wear
    • seen more in grinding than clenching
57
Q

What special investigations can be carried out for a patient with suspected temporomandibular dysfunction?

A
  • not usually required but can carry out if there is a suspicion of pathology
  • OPT
    • used to exclude dental pathology
    • condyles can be seen on the OPT
      • not particularly helpful for TMD
  • CT/CBCT
    • can request specifically of the joint
    • not routine
    • if pathology is suspected can consider
  • MRI
    • not routine
    • if suspect disc displacement
    • shows the position of the disc in function
  • transcranial view
    • TMJ view
    • not common
  • nuclear imaging
    • technetium-99 isotope
    • used for hyperplasia patients
    • isotope injected into joint
    • isotope taken up more in areas of increased cellular activity
    • imaging picks up hot spots
  • arthrography
    • solution injected into joint
    • image taken for examination
  • ultrasound
    • provides limited information
    • can determine whether displacement with or with our reduction
58
Q

What are the common clinical features of temporomandibular dysfunction?

A
  • females>males
    • may just be more females present
    • males more reluctant to seek treatment
  • most common 18-30 years old
    • can be seen in all ages
  • intermittent pain for several months/years
  • muscle/joint/ear pain
    • particularly on waking
      • when clenching
    • worsen throughout day
      • when habitual
  • trismus/locking
  • clicking and popping joint noises
    • can be audible to people around them
  • headaches
    • if temporalis aches it can feel like a headache
  • crepitus
    • indicates late degenerative changes
    • as opposed to disc displacement
59
Q

What could a differential diagnosis for a patient presenting with potential temporomandibular disfunction include?

A
  • dental pain
    • often confused with third molar pain
  • sinusitis
  • ear pathology
    • due to shared innervation
    • must have a doctor check ears
  • salivary gland pathology
    • parotid gland proximity to TMJ and masseter
    • suspicious if only unilateral symptoms
  • referred neck pain
  • headache
  • atypical facial pain
    • most common in post-menopausal women
    • can distinguish with thorough history
  • trigeminal neuralgia
    • very different presentation to TMD
    • can differentiate with a thorough history
  • angina
    • referred pain
    • small region posterior to angle of the mandible supplied by C2 which also supplies the heart
  • condylar fracture
    • history of trauma
  • temporal arteritis
    • inflammation of the temporal ateries
    • severe pain anterior to temporalis
    • usually unilateral but can be bilateral
    • worrying as can result in blindness
    • high dose steroid given by doctor
    • biopsy performed by vascular surgeon
60
Q

What treatment options are available for temporomandibular dysfunction?

A
  • reversible
    • patient education
    • counselling
    • physiotherapy
      • jaw exercises
  • medication
  • irreversible
    • occlusal adjustment
    • surgery
61
Q

What reversible treatment options are available for temporomandibular dysfunction?

A
  • counselling
    • patient must understand their condition
    • no quick fix as is a chronic condition
  • electromyographic recording
  • physiotherapy
    • jaw exercises
  • massage/heat
    • attempts to reduce inflammation
  • acupuncture
  • relaxation
  • ultrasound therapy
    • different frequency than used in imaging
    • produces heat
    • less popular as heat application works
  • TENS
    • transcutaneous electronic nerve stimulation
    • specialist pads available for the face
  • hypnotherapy
    • most successful when combined with CBT
    • not commonly available on NHS
  • splints
    • hard
    • soft
    • bite raising appliance
    • anterior repositioning splint
      • less commonly used
62
Q

What medication options are available for patients with temporomandibular dysfunction?

A
  • NSAIDs
    • caution with asthma, pregnancy and GI
  • muscle relaxants
    • can be addictive
  • tricyclic antidepressants
    • muscle relaxant effect
    • can cause drowsiness
  • botox
    • paralysis of masseter
    • reduces clenching habit
    • can get condition under control
    • not first line
  • steroids
    • injection into the joint to reduce inflammation
63
Q

What conservative management advice can be given to patients?

A
  • reassurance
  • soft diet
  • masticate bilaterally
    • even if painful
    • will make pain worse if unilaterally
  • no wide opening
    • should still allow for talking and eating
  • no chewing gum
  • don’t incise food
  • cut food into small pieces
  • stop parafunctional habits
    • nail biting
    • grinding
  • support mouth on opening
    • yawning
64
Q

What splint options are available for temporomandibular dysfunction?

A
  • anterior repositioning splint
    • less commonly used now
  • Essix retainer
    • too thin to make a difference
    • should not be used unless only trying to make patient aware of when they are clenching and grinding
  • Wenvac splint
    • soft
  • Michigan splint
    • hard
    • usually used on upper
    • bulge in canine region for guidance
  • bite raising appliance
    • hard acrylic
    • better compliance with lower appliances
65
Q

What is the best type of splint for temporomandibular dysfunction

A

It is patient variable which type of splint is best so provided all of the biting surfaces of the arch contained in the splint are covered, the splint may provide relief

66
Q

Why must all of the teeth in an arch be included in a splint?

A

to prevent extrusion of uncovered teeth

67
Q

What is a Lucia Jig?

A
  • bite raising appliance
    • only for temporary jaw relaxation before attempting to get a patient in centric occlusion
    • choking hazard
68
Q

How to bite raising appliances work and when should they be used?

A
  • exact mechanism unknown
    • little evidence to support use
    • potentially placebo effect
    • highlights cleaning
      • increases awareness of habit
  • theoretically stabilise occlusion
    • improve muscle of mastication function
    • protect teeth from grinding
  • must be worn for several weeks for benefit
    • worn at times of parafunction
69
Q

What irreversible treatment options are available for temporomandibular dysfunction?

A
  • occlusal adjustment
    • rarely done
    • no evidence of benefit
  • TMJ surgery
    • rarely done
    • does not deal with underlying cause
      • temporary solution
      • symptoms will recur
    • high risk to facial nerve
70
Q

What different surgical options are available for temporomandibular disfunction?

A
  • arthrocentesis
    • joint is cleaned out
      • saline
      • hyaluronic acid
  • arthroscopy
  • disc-repositioning surgery
  • disc repair/removal
  • high condylar shave
  • total joint replacement
71
Q

What is disc displacement?

A
  • internal derangement of the temporomandibular joint
  • patients present with painful clicking of TMJ
  • joint clicks due to lack of coordinated movement between the condyle and articular disc
  • condyle must overcome mechanical obstruction before full joint movement can be achieved
  • clicks can appear on opening or closing and can be classified as early, middle or late
72
Q

What causes disc displacement in the temporomandibular joint?

A
  1. increased pressure in the joint
  2. disc slips in front of the joint when the mouth is closed
  3. the condyle moves normally on opening initially
  4. condyle is met with resistance
  5. disc slips back into place
  6. full opening is possible
  7. disc may become displaced on closing
73
Q

What is the most common cause of temporomandibular joint clicking?

A
  • anterior disc displacement with reduction
    • disc displaced anteriorly by condyle
    • on opening disc reduction occurs
74
Q

What are the signs and symptoms of anterior disc displacement with reduction?

A
  • jaw tightness or locking
    • jaw movement impaired for a short period
      • until disc reduces
  • deviation of the mandible
    • towards the affected side
    • returns to midline
75
Q

What are the risks of anterior disc displacement with reduction?

A
  • may put more stress on the joint
    • may progress to osteoarthritis
  • little evidence and most people develop osteoarthritis in the TMJ throughout their life
76
Q

What treatment is available for anterior disc displacement with reduction?

A
  • counselling and patient education
  • limit mouth opening
  • bite raising appliance
    • rests the joint
  • surgery
    • rarely required
  • no treatment
    • if painless
    • reassure
77
Q

How can truisms and trauma be connected?

A
  • trismus can occur after minor traumatic events
    • IDB
    • prolonged dental treatment
    • infection
  • haematoma likely formed in medial pterygoid causing spasm
  • usually resolves spontaneously
78
Q

How should trismus from trauma be treated if there is no spontaneous resolution after the acute phase?

A
  • physiotherapy
    • stretches muscles
  • therabite
    • jaw motion rehabillitation system
    • plates slide between teeth
    • handles squeezed to bring jaw apart
    • measurements taken to monitor
    • eventually should return to normal
    • sometimes available on the NHS
    • alternatively use tongue depressors
  • jaw screw
    • made of wax or acrylic
    • patient bites on groove and twists to open the jaw

BDS4 Oral Surgery (2 decks)

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