TMJ Disorder Flashcards
What is blood supply and nerve supply to tmj?
Deep auricular artery - 1st part of maxillary artery
Auriculotemporal nerve, masseteric and posterior deep temporal nerve
Briefly describe the anatomy of the TMJ
Upper and lower synovial cavity separated by an articular disc
Condyle sits in the mandibular fossa with the articular tubercle anterior to the fossa
Give some possible causes of tmj disorder
Localised osteoarthritis or even rheumatoid arthritis
Disc displacement with / without reduction
Myofascial pain - muscle / fascia issue
Parafunction
Chronic recurrent dislocation
Ankylosis
Hyperplasia - facial asymmetry due to condyle hyperplasia
Neoplasia - tumour
Infection
Pathogenesis of myofascial pain with the TMJ?
Inflammation of MOM or TMJ due to parafunctional habits
Trauma directly or indirectly
Stress and clenching
Psychogenic
Occlusal abnormalities??? - no evidence however significantly high restoration / overeruption can cause pain
What E/O and I/O features may present in someone with TMJD
Hypertrophy of MOM
Clicks or crepitus in TMJ
Facial asymmetry
Cheek biting / linea alba
Tongue scalloping
NCTSL
Typical clinical features for TMJD?
More common in females
18-30 yo usually
Intermittent pain of several months / years
Muscle, joint, ear pain particularly on wakening
Trismus
Clicking or popping TMJ
Headaches
What are some possible differential diagnoses that can be confused with TMJD?
Dental pain
Ear pathology
Salivary gland pathology
Referred neck pain
Headache
Trigeminal neuralgia
Angina
Condylar fracture
Temporal arteritis
What are some treatments for TMJD
Patient education and counselling
- jaw exercises and physiotherapy
- mouth guard / soft splint - bite raising appliance
- occlusal adjustment if very pronounced
- relaxation techniques
- massage or heat
- TENS
- ultrasound therapy
- hypnotherapy/CBT
Medication
- masseter Botox
- nsaids
- muscle relaxants
- steriods
What is anterior disc displacement with reduction? Typical presentation?
Articular disc does not move coordinated with the condyle
Condyle moves forward but disc stuck anterior preventing opening
Jaw manipulation allows jaw to fully open accompanied by a pronounced popping or clicking sound
How treat anterior disc displacement with reduction?
If painless, no treatment required and just reassure
If pain
- counselling and patient education
- limit mouth opening
- bite raising appliances
- possibly surgery
What are TMDs?
Group of related MSK conditions affecting masticatory muscles, the TMJ and associated structures
What are the categories of TMDs?
Myalgia / myofascial pain
Arthralgia
Intra-articular disorders
Headache - typically confined to temporal region
Chronic - longer than 3 months
Acute - short duration, self-limiting and may be related to prolonged jaw opening
When should a TMD be suspected?
Patient presents with one or more of clinical features:
- pain in and around TMJ / MOM which may radiate to other structures. Pain may be provoked by palpation of TMJ or muscles, jaw movement, function or parafunction
- reproducible joint nose of the TMJ, clicking, popping or crepitus
- headache limited to temporal region
- otalgia / tinnitus in the absence of ear disease
When should TMD be referred to OMFS / OM?
- history of trauma / fracture to tmj
- marked limited mouth opening
- pain in jaw in patients with known rheumatic disease
- recurrent dislocation
- persistent or worsening chronic (3 month) symptoms despite primary care tx
- inability to manage normal diet
- severe pain / dysfunction
- uncertain aetiology / diagnosis
What approach should be taken to manage TMD?
Psychosocial approach
- disease education
- reassurance it should improve and is non-progressive
- info on self management such as:
- soft diet, resting the jaw if acute pain, avoiding parafunctional habits, applying ice or heat to the area
- giving paracetamol or ibuprofen for acute onset
- consider short course of diazepam for myofascial pain or amitriptyline / gabapentin for chronic TMD if appropriate
Consider referral to physiotherapist / CBT
Give some possible causes of TMDs
Internal derangement of TMJ
Macrotrauma - fall and hit chin
Micro trauma - parafunction such as bruxism, leading to overloading and cartilage breakdown in TMJ
Psychosocial - stress /anxiety predisposing parafunction
Systemic / pathological - associated with migraine, fatigue, IBS or other chronic pain. RA / SLE or arthritis too
Prognosis of TMD?
5-10% require tx
Spontaneous resolution in 40%
50-90% improve with conservative tx
Factors associated with poorer prognosis TMD?
Females
Later age onset
More severe pain = poorer prognosis
Having an associated psychosocial disorder e.g. anxiety or depression
Poor coping skills
What is the anatomy of the TMJ joint
Synovial joint with two caverns
Split in the centre by a fibrocartilaginous disc
The superior cavity allows for protrusive and lateral movements, the inferior cavity, rotational, elevation and depression movements of the mandible
Condyle of the mandible inserts into the temporal fossa of the temporal bone, just posterior to the articular eminence - a section of the zygomatic arch
What is myalgia / myofascial pain
Pain caused by masticatory muscle disorders
What is arthralgia?
Localised degeneration of the TMJ
Pain from within the joint
What is an intra-articular disorder/derangement?
Disorder of articular disc in TMJ, often caused by abnormal relationship or misalignment of the disc relative to condyle
What ligaments support the TMJ?
Lateral TMJ ligament
- joined to the inferior border of the zygomatic arch and the posterior neck of the condyle of the mandible - limits posterior movement
Medial ligaments - limit lateral movement
- stylomandibular ligament - styloid process to medial surface of the ramus
- Sphenomandibular ligament - wing of sphenoid to surrounding the mandibular foramen
What is the normal range for opening of the mouth
Incisal edge to incisal edge?
35-45mm
DD with reduction vs without reduction
Disk displacement with reduction typically manifests with clicking/popping and pain with jaw use (such as chewing).
Disk displacement without reduction does not manifest with clicking/popping, but maximum jaw opening is limited to ≤ 30 mm. Surrounding tissues may become painfully inflamed (capsulitis).
