TMJ Flashcards
1
Q
common presentation of TMJ pain (socrates)
A
S = TMJ, MOM, ear
O = sudden or gradual
C = aching, deep +/- acute sharp flares
R = ear, angle of jaw, temple, teeth
A = parafunction, occlusal issues
T = continuous +/- acute flares
E
- chewing, yawning, prolonged mouth opening
- rest and analgesia can help
S = variable
2
Q
give some differential diagnoses for TMJ pain (anatomical sieve, up to 6)
A
- dental = caries, cracked tooth
- sinus = sinusitis
- vascular = giant cell arteritis
- neuropathic = TN, TACs
- headache = tension, migraine
- malignancy
3
Q
describe giant cell/temporal arteritis (what, age, s/s, management)
A
- vasculitic condition, medical emergency
- > 50yo
- unilateral
- jaw claudication, tenderness over temporal region, frequent severe headaches, vision issues (double, loss)
- may lead to blindness
- needs to go to A&E urgently for high dose corticosteroids (preserve vision)
4
Q
how does trigeminal neuralgia pain usually present?
A
- paroxysmal unilateral lancinating pain with refractory periods
- affecting ≥1 dermatomes of trigeminal nerve
5
Q
briefly describe the anatomy of the TMJ (3)
A
- temporal aspect = S shaped with articular eminence and glenoid fossa, covered with fibro-cartilage
– articular fossa deepens with age until adulthood - ellipsoid-shaped condyle connected to mandible by narrow neck
– convex rounded/flattened mediolateral surface with “poles” - biconcave fibrocartilage articular disc
6
Q
what are the three movements of the condyle on mouth opening?
A
- hinge/rotation (up to 20mm)
- translation
- secondary rotation
7
Q
how may the TMJ be imaged? (6)
A
bony:
- panoramic/DPT (open and closed views)
- CBCT
- facial bone views = PA condyles, reverse Townes, etc
- medical CT
- nuclear medicine (hyperplasia, tumours)
soft = MRI (US limited for TMD)
8
Q
what are the pros and cons of using DPT to view TMJ? (3/5)
A
+:
- open and closed views (open less likely to show superimposition)
- simple
- tomographic (overcomes superimposition issues)
-:
- superimposition may prevent view of articular surface
- oblique view (not true lateral)
- lacks sharp detail
- normal DPT = protruded position
- cannot see soft tissue
9
Q
what are the different types of disorders affecting the TMJ? (5)
A
- developmental = hypo/hyperplasia, bifid
- trauma, dislocation, fracture
- inflammatory or degenerative
- neoplastic
- TMD (temporomandibular dysfunction/myofascial pain dysfunction syndrome)
10
Q
describe condylar hypoplasia (presentation, association, radiograph)
A
- unilateral with asymmetry
- commonly seen with hemifacial microsomia
radiograph: - small condyle, thin condylar neck with backward curvature
- antegonial notching of lower border of mandible (increased muscle activity)
11
Q
describe hemifacial microsomia (what, s/s)
A
- developmental H&N anomaly
- decreased growth and development of face, typically unilateral
- first and second branchial arches (maxilla, mandible, zygoma, ear)
- shortened ramus, hypoplastic or rudimentary condyle, elongated coronoid
- facial asymmetry, malocclusion, delayed tooth eruption
12
Q
describe condylar hyperplasia (what, demographic, s/s)
A
- unilateral, enlargement of head or elongated condylar neck
- condyle keeps growing after puberty (cartilage), self-limiting
- post-puberty, females
- mandibular asymmetry with posterior open bite
13
Q
describe bifid condyle (aetiology, appearance)
A
- possibly developmental or traumatic
- asymptomatic incidental finding
- vertical depression/notch on condylar head
- may resemble tumour but has normal cortical outline and cancellous bone
14
Q
give 3 developmental abnormalities of the condyle
A
- hypoplasia
- hyperplasia
- bifid condyle
15
Q
what are the two traumatic disorders of the TMJ?
A
dislocation
fracture
16
Q
describe dislocation injury of the TMJ (what, presentation, causes)
A
- displacement of condyle to a position anterior to the articular eminence but within the capsule, such that the mouth remains in the open position
- elongated facial appearance with notch just anterior to ear
- due to acute trauma (blow whilst mouth open) or yawning, mandibular XTNs, prolonged RCT
- chronic - neuromuscular imbalance, lax capsular ligaments, flat articular eminence
17
Q
define dislocation injury of the TMJ
A
- displacement of condyle to a position anterior to the articular eminence but within the capsule
- such that the mouth remains in the open position
18
Q
what may increase the risk of chronic TMJ dislocation? (3)
A
- neuromuscular imbalance
- lax capsular ligaments
- flat articular eminence
19
Q
what type of fracture(s) is likely from a blow to the chin point?
A
bi or unilateral fracture
20
Q
what type of fracture(s) is likely from a blow to the side of the mandible?
A
- fracture at point of impaction
- AND of opposite condylar neck (contrecoup fracture)
21
Q
why are many condylar fractures “displaced”?
A
muscle pull (usually forward and medially by lateral pteryoid)
22
Q
are intra or extracapsular TMJ fractures more common?
A
extracapsular (condylar neck is a weak point)
23
Q
how may TMJ fractures present? (3)
A
- pain and swelling over the affected TMJ, or minimal symptoms
- deviation of mandible to affected side on opening
- possibly anterior open bite if bilateral condylar fracture
24
Q
what imaging may be used to view TMJ fractures?
A
- often DPT and PA condyles or reverse Townes (2 views at right angles)
- +/- CBCT/medical CT
25
what radiographic signs may indicate degenerative joint disease (TMJ)? (4)
- irregular condyle outline, erosions of articular surface of condyle or osteophyte formation
- loss of cortication
- RL beneath condylar head (Ely cyst/subchondral RL)
- bony sclerosis (increased density, inflammatory response)
26
describe degenerative TMJ disease (s/s, age, radiograph)
- similar symptoms to TMD + grating sound/sensation (crepitus) on palpation
- usually local disease > generalised
- older adults
radiograph
- irregular condyle outline, erosions of articular surface of condyle or osteophyte formation
- loss of cortication
- RL beneath condylar head (Ely cyst/subchondral RL)
- bony sclerosis (increased density, inflammatory response)
27
describe myofascial pain (TMJ) (what, examination)
- tenderness of facial and neck muscles (mainly MOM), can be associated with stress, bruxism or following dental tx
- palpate MOM, IO signs of bruxism
- no imaging usually needed
- managed conservatively first
28
what is disk displacement/internal derangement of disk (TMJ)? (what, any associations)
- disk anteriorly displaced when the mouth is closed
- on opening, disk reduces back to normal position with a click or stays anterior (reduced MO)
- may be associated with myofascial pain
- no abnormal bony changes
(may use MRI if unresponsive to treatment)
29
what are the two different types of disk displacement (TMJ)?
- anterior displacement with reduction (normal mouth opening, click as disk reduces to normal position)
- anterior displacement without reduction (reduced MO, disk stops condyle moving forward)
30
describe ankylosis of TMJ (what, s/s, types, investigation)
- fusion of condyle to temporal or zygomatic bone
- progressive decrease in mouth opening, limited/no condylar movement
- fibrous or bony
- altered radiographic outline needing CBCT or CT
31
give possible aetiologies of TMJ ankylosis (up to 8)
- congenital
- inflammatory (eg suppurative arthritis)
- trauma
- neoplastic
- scleroderma (autoimmune)
- radiation therapy
- TMJ operations
- idiopathic
32
what is the difference between intrinsic and extrinsic TMJ tumours?
- intrinsic = from within joint
- extrinsic = from outside TMJ but involve the TMJ
33
give 3 examples of benign tumours affecting the TMJ, which is the most common?
- osteochondroma most common
- chondroma
- giant cell granuloma
34
how may osteochondroma affecting the TMJ present? (clinical, radiograph)
- slow-growing
- swelling
- asymmetry
- limited mouth opening
- irregularly shaped radiopaque enlargement of condyle (usually anterior aspect)
35
give 3 examples of malignant tumours that may affect the TMJ, which is the most common?
- secondary deposits most commonly
- chondrosarcoma
- osteosarcoma
36
how may malignant tumours affecting the TMJ present? (clinical, radiograph)
- pain, discomfort
- restricted mouth opening
- swelling
- bone destruction = RL with loss of condyle definition
37
why is it especially important to diagnose malignant TMJ tumours early?
to limit the likelihood of spread into the middle cranial fossa
38
describe the epidemiology of TMD (gender, type, age)
- more in females
- most are recurrent, some are single episode or persistent
- s/s peak at 20-40yo
39
what is the difference between acute and chronic TMD?
- acute = short duration, self-limiting, often linked to specific trigger (stress, trauma)
- chronic = >3 months and may fluctuate
40
define temporomandibular disorders
collective term of musculoskeletal problems involving the MOM, TMJ and associated structures
41
what are the MOM diagnostic criteria for TMDs?
- myalgia (one muscle), myofascial pain (muscle and fascia) +/- referral, regional pain (multiple muscles)
(tender to palpation, possible limited mandibular function due to pain)
42
what are the TMJ diagnostic criteria for TMDs? (7)
- arthralgia, temporal area headache
- disk displacement disorders
- inflammatory disorders (capsulitis, arthritis)
- dislocation, fracture
- deviation in form
- ankylosis
- tumour
43
how may myalgia/myofascial pain present (TMD)? (history, 4)
- regional, dull aching pain at rest, aggravated during function - masseter and temporalis
- more painful in morning (nocturnal parafunction)
- referral of pain = headache, fullness of ear, neck pain
- possible limitation of movement
44
how may arthralgia present (TMD)? (history, 5)
- localised sharp pain, aggravated during loading and function
- around the TMJ, surrounding tissues and ear
- associated with (not caused by) displaced/dysfunctional disk
- possible limitation of movement
- +/- generalised arthritis, often with crepitus
45
describe the aetiology of TMDs
- genetics, female
- peripheral and central sensitisation
- comorbidities - fibromyalgia especially
- biopsychosocial: (onset, development and maintenance of chronic pain)
-- parafunction, chewing gum
-- trauma, inflammatory disease, occlusion
-- stress, anxiety, hypervigilance, catastrophising
-- race/ethnicity, SE factors, pt beliefs
46
describe the 3 step examination protocol for TMDs
1 Joint examination
- any pain on TMJ palpation or wide opening
- any joint sounds
2 Muscle examination
- neck/shoulder muscles
- masseter and temporalis (EO)
- insertions of lateral and medial pterygoids (IO) + TSL, signs of parafunction, occlusal derangement, high restorations
3 Functional examination
- deviation and pattern of mouth opening and excursions
- >30mm functionally sound
47
what is normal mouth opening (mm)?
35-45mm between incisors (3 of pt's fingers)
(>30mm functionally sound)
48
what are the three phases of TMD management?
- phase I = reversible conservative tx
phase II = irreversible management (minimal evidence)
phase III = irreversible treatment
49
describe phase I of TMD management (8)
(reversible, conservative)
- pt education - facilitate engagement, develop coping skills, reassurance, signposting, informative prescription
- analgesia - mostly OTC, benzodiazepines for acute pain
- jaw exercises, physiotherapy
- relaxation, mindfulness, CBT, decrease stress
- acupuncture (short term, good for masseter)
- bite raising appliance (soft or Michigan splint)
- heat/cold application
- pharmacological management
50
what pharmacological means may be used in phase I management of TMDs? (3)
- acute = paracetamol, NSAIDs (esp topical), short course of benzodiazepines (trismus)
- chronic = tricyclic antidepressants used off-label by specialist or GP (11-12 weeks before effective)
- botox may help for dislocations or hypertrophic muscles
51
what is involved in the education part of phase I management of TMDs? (7)
- facilitating pt engagement
- developing coping skills
- reassurance
- signposting
- informative prescriptions
- what TMD is and how it causes pain
- avoiding parafunctional habits (chewing gum or pens, soft diet), resting muscles
52
what may be involved in phase II of TMDs management? (4)
- occlusal therapy and restorative treatment
- prosthodontic reconstruction
- orthodontics
- surgery (orthognathic if severe skeletal discrepancy)
53
what additional specialist treatments may be used for chronic/unresponsive TMDs? (5)
- muscle relaxants (baclofen, diazepam)
- intramuscular or intra-articular LA (dx and tx)
- intra-articular steroids (depo-medarone) - long term associated with condylar hypoplasia
- arthroscopy/arthrocentesis often with steroids
- joint surgery only if serious functional issues
54
when might joint surgery be indicated for TMDs? (4)
- mandibular growth disturbances
- ankylosis
- tumours
- secondary conditions - arthritis, fracture of condyle with dislocation, anterior disk displacement with severe functional issues, recurrent mandibular dislocation
55
name some of the types of extra-articular TMJ surgery (4)
- condylotomy
- condylectomy
- whole joint replacement
- orthognathic surgery
56
what is involved in phase III TMDs management?
diagnostic and therapeutic TMJ arthroscopic surgeries
