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Oral Surgery > TMJ > Flashcards

TMJ Flashcards

1
Q

unlike oteher joints TMJ enclosed with

A

fibrous tissue

articular disk that is biconcave

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2
Q

bones with TMJ

A

mandible and cranium bone

portion of mandible = condylar process– bulbous and elongated m-d and flattened a-p

cranial bone = temporal bone

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3
Q

help in diangosis / evaluation

A

history

clinical exam

imaging studies

arthroscopy - joint exam

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4
Q

___ may be the most important part of evaluation

A

history - interview

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5
Q

disroders include

A

myofacial pain and dysfunction (MPD)

internal derangements

degenerative joint disease

systemic arthritic conditions

chronic recurrent dislocation

ankylosis

neoplasm

trauma

infections

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6
Q

physical exam

A

evaluation of the masticatory system (asymmetry, hypertrophy, clenching)

muscles palpated for tenderness, fasiciculations, spasm, trigger points

note any tenderness and noise

  • note the range of opening

dental evaluation?
- wear? occlusion?

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7
Q

mandibular range of motion

A

normal is 45 mm vertically and 10 mm protrusive and laterally

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8
Q

dental evalutiaon

A

wear facets, occlusal relationships, CR/CO relationship

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9
Q

internal derangements diagnostic toolls

A

IMAGING

  • transcranial
  • panoramic
  • tomogram
  • arthrography
  • CT scan
  • MRI
  • nuclear imaging
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10
Q

panoramic use

A

one of the best radiographs for overall screening evaluaiton of the TMJ’s

visualization of both TMJ’s on same film

provides good assessment of the bony anatomy of the articulating surfaces of the mandibular condyle and glenoud fossae, and other areas

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11
Q

tomograms

A

allows radiographic sectioning at different levels of the condyle and fossa complex,

provides individual view visualizing the joint in SLICES from the medial to the lateral pole

eliminates bony superimposition and overlap

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12
Q

which gives a clearer picture of the bony anatomy

A

TOMOGRAMS

Can see degenerative condylar changes

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13
Q

TMJ arthrography

A

first imaging techniue available to visualize the intraarticular disk

injection of contrast material into the inferior or superior spaces of the joint

demonstrates the presence of perforations and adhesions of the disk or its attachments

RARELY used today

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14
Q

computed tomography

A

combination of tomographic views of the joint, combined with computer enhancement of hard and soft tissue images

CT images provide the MOST ACCURATE radiographc assessment of the BONY components of the joint

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15
Q

most accurate radio assessment

A

Computed Tomography

CT

example - diagnosis of fibro-osseous ankylosis

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16
Q

MRI

A

most effective for TMJ soft tissue

valuable technique for evaluating disk morphology and position

images can be obtained showing dynamic joint function

no ionizing radiation used

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17
Q

most effective for TMJ soft tissue

A

MRI

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18
Q

degenerative condylar changes seen when

A

later on in stages of disease

initially just usually pain and discomfort not necessarily radiographic changes

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19
Q

nuclear imaging

A

involves injection of Tc99 which is concentrated in areas of active bone metabolism

images taken 33 hours after injection

information obtained can be difficuly to interpret

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20
Q

classification of TMJ disorders

A

myofacial pain

disk displacement disorders

DJD

systemic arthritic conditions

chronic recurrent dislocation

ankylosis

neoplasm

infections

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21
Q

MRI look at

A

disk!!

fibers
muscles

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22
Q

main features of myofacial pain and dysfunction (MPD)

A
  1. abnormal or hyperactive muscle activity
    - clenching / bruxims
  2. diffuse, poorly localized pain
    - headaches, bitemporal
  3. NO JOINT NOISES
  4. usually no radiographic abbnormalities

THE MOST COMMON CAUSE OF MASTICATORY PAIN AND LIMITED FUNCTION FOR WHCIH PT’S SEEK TX.

MOSTLY WITH THE MUSCLES AND JOINTS
- not really bone
- could be neck / trapezius as well
with referred pain

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23
Q

MPS management?

A

MPS may settle without medical intervention within 5-10 days but if they become chronic can be quite disabling

early diagnosis and targeted treatment may prevent chronicity occuring

the aim of MPS management is PAIN RELIEF AND RESTORATION OF FULL MUSCLE FUNCTION, which is associated with complete muscle length, posture, and full range of motion, to avoid chronic complications such as muscular dystrophy and permanent disability

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24
Q

MPD treat?

A

enhancing central inhibition – pharmocologial and or behavior techniques and reducing periheral inputs using physical therapy

correct unconscious postural habits

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25
Q

methods of inactivation of inactivation of TP’s for?

A

myofacial pain

dysfunction syndrome

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26
Q

forward translation should come back to

A

12 o clock position

deviation from this referred to as internal derangeemnt

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27
Q 
anterior disk displacement with reduction 
describe and form of?
closed position?
open position?
during closing?
A

type of internal derangement

disk is positioned anteiror and medial to the condyle in the closed position

during opening - condyle translates forward and passes over thickened posterior band of disk, creatinga clicking noise

during closure - the condyle slips posteriorly and rests on the retrodiscal tissues - with the disk then returning to the anterior, medially displaced position

joint and muscle tenderness - opening and reciprocal clicks are noted

with reduction – disk COMES BACK
- patient usually presents with limited mouth opening

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28
Q

anterior disk displacement withOUT reduction
describe and form of?
affected side?
contralateral side?

A

the disk displacement cannot be reduced and thus the condyle is unable to translate to its full anterior extent

prevents maximal opening and causes deviation of the mandible to the AFFECTED SIDE

and decreased ateral excursions to the contralateral side

NO clicking - b/c the condyle does not translate over the posteiror aspect of the disk

fails to come back to position in 12 oc lcok position

  • now lined in different position
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29
Q

anterior disk displacement with reduction

describe and form of

A

with reduction – disk COMES BACK
- patient usually presents with limited mouth opening

BOTH OPEN AND CLOSED CLICK

30
Q

disk position

A

anterior and medial to the condyle in the closed position

31
Q

wilkes classification of

A

internal derangement of the TMJ

i- V

I–V

32
Q

wilkes classification of internal derangement of TMJ that does not reduce

A

internal derangement of the TMJ

stage III - no reduction
more frequent pain and tenderness in the joint, associated with headaches and locking and restrcted motion
- no degenerative osseous changes

IV and V can see disk perforations and degenerative osseous changes

33
Q

DJD cuases usually by (3 main)

degnerative joint disease

A

direct mechanical trauma

hypoxia reperfusion injury

neurogenic inflammtion

34
Q

symptoms of DMJ

A

pain, localized to the joint

headaches

ear pain

clicking

crepitus

limited opening

symproms usually increase with function

35
Q

DJD radiographic findings

A

CT needed to compliment MRI

irregular perforated disks

dereased joint space

flattened of condyle

erosion of cortex of condyle

osteophyte formation**

36
Q

rheumatoid arthritis is a?

describe

A

systemic arthritis condition

  • usually TMJ in only one of several joints affected
  • usually bilateral
  • contrasted to DJD- can occur at any age
  • abnormal proliferatio of synovial tissue
37
Q

chronic dislocation

A

condyle is displaced anteriorly and is locked in front of articular eminence (temporal bone)

severe muscle spasms

pain

38
Q

put disc back how

A

bring down back and up

39
Q

chronic disloaction tx

A

surgical
- reserved for severe cases

eminectomy
- aricular eminence is removed so that condyle can return to glenoid fossa

40
Q

eminectomy

A

aricular eminence is removed so that condyle can return to glenoid fossa

elimination of the eminance

flaten out the eminence – remove that portion of the bone

41
Q

intracapsular ankylosis

most common etiology?

A

fusion of joint due to formation of bone or fibrous tissue (or both)

most common etiology is trauma, especially in children

42
Q

types of ankylosis

A

intracapsular

extracapsualr

43
Q

extracapsualr ankylosis
involves?
caused by

A

causes - usually involves the coronoid process and temporalis muscle

  • coronoid hypperplasia

trauma to the zygomati arch

44
Q

modified kaban’s protocol

A

substitute ramus/ condyle reconstruction using DISTRACTION OSTEOGENESIS, when possible, instead of costochondral grafting

this protocol has major advanthetage of eliminating the donor site operation and allowing for immediate vigorous TMJ mobilization

45
Q

the most common cause of masticatory pain and limited function for which patients seek treatment

A

myofacial pain and dysfunction

  • no joint noises
  • usually no raiogtpahic abnormalties
46
Q

aim in MPS management

A

the aim of MPS management is PAIN RELIEF AND RESTORATION OF FULL MUSCLE FUNCTION, which is associated with complete muscle length, posture, and full range of motion, to avoid chronic complications such as muscular dystrophy and permanent disability

47
Q

affected vs contralateral side in anterior disk displacement without reduction?

A

affected side – deviation of mandible to this side

contralateral side – decrease in lateral excursions to the contra lateral side

48
Q

clicking in anterior disk displacement without reduction?

A

NO – because condyle does not translate over the posterior aspect of the disk

there is an opening and closing click in with reduction

49
Q

internal derangment - general

A

th disk is positioned anterior and medial to the condyle in the closed position

has to pass over thickened posterior aspect to open

50
Q

closing click

A

in anterior disk displacement with reduction

- condyle goes back posteriorly and the disc returns to the anterior medially displaced position

51
Q

assessment of clicking

A

it is a brief noise that occurs at some point during opening, closing, or both

52
Q

assessment of crepitus

A

it is a diffuse, sustained sound usually felt throughout a considerable portion of the opening or closing cycle or both

53
Q

assessment of reciprocal click

A

noise made on opening and closing from centric occlusion that is reproducible on every opening and closing
- early stage disk disorder

54
Q

sign of early stage disk disroder

A

reciprocal click and popping

55
Q

assessment of reproducible opening click

A

noise with every opening
no noise when closing
deviation in form of disk or late stage disk disorder

56
Q

assessment of reproducible closing click

A

noise with every closing, no noise when opening

- deviation in form of disk

57
Q

assessment of popping

A

loud sound on opening that is audible to examiner at a distance
- early stage disk disorder

58
Q

best to study internal derangments / disk displacment disorders

A

MRI

demonstrates position of articular disk
- open and closed mouth views are needed to study disk

can demonstrate joint effusion or other soft tissue abnormalities

59
Q

can see osteophyte formation in?

A

radiogrpahic finding of degenerative joint disease

60
Q

contrast RA with DJD

A

DJD - usually getting worse with time and age

whereas RA can occur at any age aa it is a systemic arthriic condition

61
Q

clinical evaluation of intracapsular vs extracapsular ankylosis

A

intracapsular

  • severe restirction of maximal opening
  • deviation to the affected side
  • decreased lateral excursions to the lateral side

extracapsular

  • limitation of opening
  • deviation to the affected side -
  • limited lateral and PROTRUSIVE movements can usually be performed (think of the temporalis muscle involvment)
62
Q

major difference between modified kaban’s protocol and kabans protocol

A

modified
- uses DISTRACTION OSTEOGENESIS instead of osteochondral grafting

so substitutes ramus/ condyle reconstruction using this technique

63
Q

basic for kaband protocl

A

calls for aggressive resection and ipsilateral coronoidectomy and contralateral coronoidectomy when necessary

line the TMJ with temporalis fascia or cartilage, reconstruction of the ramus with a COSTOCHONDRAL GRAFT

  • rigid fixation, and
  • early mobilization and agressive physiotherapy is presented

MODIFIED
- DISTRACTION OSEOINTEGRATION with no costochondral grafting

64
Q

neoplasms in the joint?

A

very rare

  • will present with pain
  • asymmetry, deviation of mandible
  • restricted opening
65
Q

infections could come from

A

from ear and could cause intrascapular ankylosis

66
Q

evidence from studies of TMD - basic conclusion

A

recent evidence has suggested that in most cases TMD may be a manifestation of chronc orofacial pain

proper dx and managment is of paramount importance

follow up is equally significant

67
Q

auto repositioning splint

A

full arch contact

disarticulates the jaws and may place condyles in posterior / retruded position, reducing the disk

allows the patient to seek a comfortable muscle and joint position without excessive influence of the occlusion

68
Q

useful tx for anterior disk displacement with reduciton

A

anterior repositioning splint

69
Q

anterior repositioning splint

A

anterior ramp forces mandible into protruded position

attempts to protrude proper condyle / disk relationship

useful for pts. with anterior disk displacement with redution

70
Q

arthrocentesis is what type of tx?

A

surgical

71
Q

arthrocentesis

A

lavage of the superior joint space with needles

steroids ma be injected into the joint

indicated for acute closed lock – non reducing anteriorly displaced disk

may relieve “suction cup effect” of disk
eliminiation of biological mediators of pain and inflammatin

very effective at reducing pain and increasing function

post-op physical therapy is essential

72
Q

indication for arthrocentesis

A

for actute closed lock – non reducing anteriorly displaced disk

Oral Surgery (26 decks)

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