TMJ Flashcards
unlike oteher joints TMJ enclosed with
fibrous tissue
articular disk that is biconcave
bones with TMJ
mandible and cranium bone
portion of mandible = condylar process– bulbous and elongated m-d and flattened a-p
cranial bone = temporal bone
help in diangosis / evaluation
history
clinical exam
imaging studies
arthroscopy - joint exam
___ may be the most important part of evaluation
history - interview
disroders include
myofacial pain and dysfunction (MPD)
internal derangements
degenerative joint disease
systemic arthritic conditions
chronic recurrent dislocation
ankylosis
neoplasm
trauma
infections
physical exam
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?
mandibular range of motion
normal is 45 mm vertically and 10 mm protrusive and laterally
dental evalutiaon
wear facets, occlusal relationships, CR/CO relationship
internal derangements diagnostic toolls
IMAGING
- transcranial
- panoramic
- tomogram
- arthrography
- CT scan
- MRI
- nuclear imaging
panoramic use
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
tomograms
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
which gives a clearer picture of the bony anatomy
TOMOGRAMS
Can see degenerative condylar changes
TMJ arthrography
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
computed tomography
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
most accurate radio assessment
Computed Tomography
CT
example - diagnosis of fibro-osseous ankylosis
MRI
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
most effective for TMJ soft tissue
MRI
degenerative condylar changes seen when
later on in stages of disease
initially just usually pain and discomfort not necessarily radiographic changes
nuclear imaging
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
classification of TMJ disorders
myofacial pain
disk displacement disorders
DJD
systemic arthritic conditions
chronic recurrent dislocation
ankylosis
neoplasm
infections
MRI look at
disk!!
fibers
muscles
main features of myofacial pain and dysfunction (MPD)
- abnormal or hyperactive muscle activity
- clenching / bruxims - diffuse, poorly localized pain
- headaches, bitemporal - NO JOINT NOISES
- 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
MPS management?
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
MPD treat?
enhancing central inhibition – pharmocologial and or behavior techniques and reducing periheral inputs using physical therapy
correct unconscious postural habits
methods of inactivation of inactivation of TP’s for?
myofacial pain
dysfunction syndrome
forward translation should come back to
12 o clock position
deviation from this referred to as internal derangeemnt
anterior disk displacement with reduction describe and form of? closed position? open position? during closing?
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
anterior disk displacement withOUT reduction
describe and form of?
affected side?
contralateral side?
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
anterior disk displacement with reduction
describe and form of
with reduction – disk COMES BACK
- patient usually presents with limited mouth opening
BOTH OPEN AND CLOSED CLICK
disk position
anterior and medial to the condyle in the closed position
wilkes classification of
internal derangement of the TMJ
i- V
I–V
wilkes classification of internal derangement of TMJ that does not reduce
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
DJD cuases usually by (3 main)
degnerative joint disease
direct mechanical trauma
hypoxia reperfusion injury
neurogenic inflammtion
symptoms of DMJ
pain, localized to the joint
headaches
ear pain
clicking
crepitus
limited opening
symproms usually increase with function
DJD radiographic findings
CT needed to compliment MRI
irregular perforated disks
dereased joint space
flattened of condyle
erosion of cortex of condyle
osteophyte formation**
rheumatoid arthritis is a?
describe
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
chronic dislocation
condyle is displaced anteriorly and is locked in front of articular eminence (temporal bone)
severe muscle spasms
pain
put disc back how
bring down back and up
chronic disloaction tx
surgical
- reserved for severe cases
eminectomy
- aricular eminence is removed so that condyle can return to glenoid fossa
eminectomy
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
intracapsular ankylosis
most common etiology?
fusion of joint due to formation of bone or fibrous tissue (or both)
most common etiology is trauma, especially in children
types of ankylosis
intracapsular
extracapsualr
extracapsualr ankylosis
involves?
caused by
causes - usually involves the coronoid process and temporalis muscle
- coronoid hypperplasia
trauma to the zygomati arch
modified kaban’s protocol
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
the most common cause of masticatory pain and limited function for which patients seek treatment
myofacial pain and dysfunction
- no joint noises
- usually no raiogtpahic abnormalties
aim in MPS management
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
affected vs contralateral side in anterior disk displacement without reduction?
affected side – deviation of mandible to this side
contralateral side – decrease in lateral excursions to the contra lateral side
clicking in anterior disk displacement without reduction?
NO – because condyle does not translate over the posterior aspect of the disk
there is an opening and closing click in with reduction
internal derangment - general
th disk is positioned anterior and medial to the condyle in the closed position
has to pass over thickened posterior aspect to open
closing click
in anterior disk displacement with reduction
- condyle goes back posteriorly and the disc returns to the anterior medially displaced position
assessment of clicking
it is a brief noise that occurs at some point during opening, closing, or both
assessment of crepitus
it is a diffuse, sustained sound usually felt throughout a considerable portion of the opening or closing cycle or both
assessment of reciprocal click
noise made on opening and closing from centric occlusion that is reproducible on every opening and closing
- early stage disk disorder
sign of early stage disk disroder
reciprocal click and popping
assessment of reproducible opening click
noise with every opening
no noise when closing
deviation in form of disk or late stage disk disorder
assessment of reproducible closing click
noise with every closing, no noise when opening
- deviation in form of disk
assessment of popping
loud sound on opening that is audible to examiner at a distance
- early stage disk disorder
best to study internal derangments / disk displacment disorders
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
can see osteophyte formation in?
radiogrpahic finding of degenerative joint disease
contrast RA with DJD
DJD - usually getting worse with time and age
whereas RA can occur at any age aa it is a systemic arthriic condition
clinical evaluation of intracapsular vs extracapsular ankylosis
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)
major difference between modified kaban’s protocol and kabans protocol
modified
- uses DISTRACTION OSTEOGENESIS instead of osteochondral grafting
so substitutes ramus/ condyle reconstruction using this technique
basic for kaband protocl
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
neoplasms in the joint?
very rare
- will present with pain
- asymmetry, deviation of mandible
- restricted opening
infections could come from
from ear and could cause intrascapular ankylosis
evidence from studies of TMD - basic conclusion
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
auto repositioning splint
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
useful tx for anterior disk displacement with reduciton
anterior repositioning splint
anterior repositioning splint
anterior ramp forces mandible into protruded position
attempts to protrude proper condyle / disk relationship
useful for pts. with anterior disk displacement with redution
arthrocentesis is what type of tx?
surgical
arthrocentesis
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
indication for arthrocentesis
for actute closed lock – non reducing anteriorly displaced disk
