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BDS4 Oral Surgery > TMJ Disorders (Dr Naudi) > Flashcards

TMJ Disorders (Dr Naudi) Flashcards

1
Q

What type of joint is the TMJ

A

synovial

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2
Q

What encloses the TMJ

A

A fibrous joint capsule completely encloses the TMJ

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3
Q

Where is the disc located

A

The fibrous disc is located between the temporal bone and the mandibular condyle on each side

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4
Q

What does the disc allow

A
  • articulation between the two bones
  • seperation of the TMJ into two compartments
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5
Q

What do the membranes that line the TMJ secrete

A

synovial fluid

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6
Q

What does the synovial fluid do

A

fills the synovial space + lubricates teh joint

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7
Q

What is the TMJ innerated by

A

CN5
branches of mandibular nerve
auriculotemporal nerve

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8
Q

How can someone confuse TMJ pain with ear pain

A

auriculotemporal nerve supplies the EAM
can result in TMJ pain being confused with an ear infection

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9
Q

Where does the TMJ blood supply originate from

A

external carotid artery with the first branch of the maxillary artery supplying the TMJ

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10
Q

What is the name of the artery that supplies the TMJ

A

Deep auriclar artery

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11
Q

Which part of the disc is not innervated

A

anterior band

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12
Q

Which part of the TMJ disc is innervated

A

the part between the posterior band and the bilaminar zone
the bilaminar zone also has a blood supply

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13
Q

Where is the masseter muscle located

A

anterior to the parotid gland

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14
Q

How many heads does the masseter have

A

2
superficial and deep

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15
Q

What is the origin of the masseter

A

zygomatic arch

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16
Q

Where in the zygomatic arch do the superficial and deep head originate

A

superficial –> zygomatic process + anterior zygomatic arch

deep –> posterior zygomatic arch + medial surface

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17
Q

Where does the masseter’s superficial head insert

A

lateral surface of angle of mandible

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18
Q

Where does the masseter’s deep head insert

A

ramus, superior to angle of the mnadible

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19
Q

What is the action of the masseter

A

elevating the mandible

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20
Q

Describe the temporalis

A
  • Broad, fan shaped muscle
  • Fills the temporal fossa
  • Superior to the zygomatic arch
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21
Q

Where does the temporalis originate

A

temporal fossa

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22
Q

Where does the temporalis insert

A

Onto the medial surface, apex and anterior border of the coronoid process of the mandible

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23
Q

What is the action of the temporalis if entire muscle contracts

A

elevates mandible

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24
Q

What is the action of the temporalis if only the posterior part of the temporalis contracts

A

retraction of the mandible

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25
Q

How many heads does the medial pterygoid have

A

2
deep and superficial

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26
Q

What is the origin of the deep head of MP

A

originates from the pterygoid fossa on the mesial surface of the lateral pterygoid plate of the sphenoid bone

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27
Q

Where does the small superficial head of the MP originate

A

lateral surfaces of the pyramidal process of the palatine bone and maxillary tuberosity of the maxilla

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28
Q

Where does the MP insert

A

Both heads then pass inferiorly, posteriorly and laterally to insert on the medial surface of the ramus/angle of the mandible

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29
Q

What is the action of the MP

A

Muscle elevates the mandible
Parallels the masseter but weaker

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30
Q

Describe the laterla pterygoid

A
  • Short, thick, conical muscle
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31
Q

How many heads does the LP have

A

2
superior + inferior

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32
Q

Where does the superior head of LP originate

A

originates from the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone

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33
Q

Where does the inferior head of LP originate

A

from the lateral surface of the lateral pterygoid plate of the sphenoid bone

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34
Q

Where does the superior head of LP insert

A

into the neck of the mandible at the pterygoid fovea

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35
Q

Where does the inferior head of LP insert into

A

into the anterior margin of the TMJ disc + capsule

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36
Q

What is the action of LP

A

o Assists in depressing the mandible by its inferior head
o Main action when both muscles contract is to bring the lower jaw forward thus causing the protrusion of the mandible
o If only one muscle is contracted, the lower jaw shifts to the contralateral side causing lateral deviation

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37
Q

What are the accessory muscles of mastication

A

suprahyoid

38
Q

Name the suprahyoid muscles

A
  • digastric
  • mylohyoid
  • geniohyoid
  • stylohyoid
39
Q

Name the infrahyoid muscles

A
  • thyrhyoid
  • sternohyoid
  • omohyoid
  • sternothyroid
40
Q

What is A

A

Mandibular fossa

aka glenoid fossa

41
Q

What is B

A

articular disc

42
Q

What is C

A

mandibular condyle

43
Q

What is D

A

articular tubercle
aka articular eminence

44
Q

What are the 2 movements of the TMJ

A

rotation + translation

45
Q

What is rotation also known as

A

hinge movement

46
Q

How mouth mouth opening does the rotation allow for

A

up to 20mm

47
Q

Where are the condyle and the disc during hinge movement

A

they remain within the articular fossa

48
Q

What is the terminal hinge axis

A

it is the imaginary line the condylar head rotates around during rotational movement of the TMJ

49
Q

What happens in translation

A
  • LP contracts
  • articular disc + condyle begin to move
  • they travel downwards and forward along the incline of the articular eminence
  • if they travel laterally then this results in lateral translation
  • it produces maximum opening of the mouht
50
Q

What are the causes of TMD

A

myofascial pain
disc displacement
degenerative disease
chronic recurrent dislocation
ankylosis
hyperplasia
neoplasia
infection

51
Q

What is disc displacement

A
  • disc slips out of place
52
Q

What is anterior displacement

A

If the disc slips anteriorly

53
Q

What is anterior displacement with reduction

A

disc slips forward but is able to go back to it’s correct place

54
Q

What is anterior displacement without reduction

A

when the disc slips forward but is unable to go back to its correct place

55
Q

What are the two types of degenerative disease

A

o Localised (osteoarthritis)
o Generalized/systemic (rheumatoid arthritis)

56
Q

What is chronic recurrent dislocation

A

o Joint regularly dislocates where it slips out of the articular eminence and ends up infront of the eminence and stuck there

57
Q

What is hyperplasia

A

o One condyle grows more than the other

58
Q

What are examples of neoplasia that cause TMD

A

o Osteochondroma, osteoma or sarcoma

59
Q

Describe the pathogenesis of myofascial pain

A

o Inflammation of the muscles of mastication or TMJ secondary to parafunctional habits
o Trauma either directly to joint or indirectly e.g sustained mouth opening
o Stress (resulting in muscle tension)
o Psychogenic
o Occlusal abnormalities (no evidence to support this)

60
Q

What does our assessment consist of

A

history
intra/extra oral exam
special investigations (sometimes)

61
Q

When looking at pain history, what do we want to focus on

A

location, nature, duration, exacerbating/relieving factors, severity, frequency, time of occurrence

62
Q

What do we look at in the extra oral exam

A

MoM
joints
jaw movement
facial asymmetry

63
Q

What are we looking at when we look at the joints

A

clicks and crepitus

64
Q

What does crepitus point at

A

degenerative change

65
Q

Intra-orally what do we look at

A

interincisal mouth opening
signs of parafunctional habit

66
Q

What are signs of parafunctional habit

A
  • cheek biting
  • linea alba
  • tongue scalloping
  • occlusal NCTSL
67
Q

When may we look at doing x-rays

A

when pathology suspected
severe trismus

68
Q

What is normal mouth opening

A

42-55mm

69
Q

What is the gold standard view for TMJ

A

MRI

70
Q

What other views can be taken for TMJD

A

 OPT
 CT/CBCT
 MRI
 Transcranial view (TMJ view)
 Nuclear imaging (tech-99)
 Arthrography
 Ultrasound

71
Q

What are the common clinical features of TMJD

A

o Females > males
o Age: most common between 18-30 YO
o Intermittent pain of several months or years duration
o Muscle/joint/ear pain, particularly on wakening (likely clenching during the night)
o Trismus/locking (due to displacement where unable to reduce)
o Clicking/popping joint noises
o Headaches
o Crepitus indicates late degenerative changes

72
Q

What are the differential diagnoses pain in TMJ area

A
  • dental pain (wisdom teeth)
  • sinusitis
  • ear pathology
  • salivary gland pathology
  • referred neck pain
  • headache
  • atypical facial pain
  • trigeminal neuralgia
  • angina
  • condylar fracture
  • temporal arteritis
73
Q

What are reversible tx for TMJD

A

px education
medications
reassurance
physical therapy
splints

74
Q

What does px education consist of

A

 Counselling
 Electromyographic recording
 Jaw exercises (physiotherapy)

75
Q

What do the medications consist of

A

 NSAIDS
 Muscle relaxants
 Tricyclic antidepressants
 Botox (to paralyse masseter to reduce clenching)
 Steroids

76
Q

What does reassurance consist of

A

 Soft diet
 Masticate bilaterally
 No wide opening
 No chewing gum
 Don’t incise foods
 Cut foods into small pieces
 Stop parafunctional habits e.g nail biting, grinding
 Support mouth on opening e.g yawning

77
Q

What does physical therapy consist of

A

 Physiotherapy
 Massage/heat
 Acupuncture
 Relaxation
 Ultrasound therapy
 TENS
 Hypnotherapy

78
Q

What are the splints in TMJD aka

A

bite raising appliance

79
Q

What are the types of bite raising appliances

A

Anterior repositioning splint
Wenvac splint
Michigan splint
Lucia jig

80
Q

What is the mechanism of bite raising appliances

A

o Exact mechanism unknown
o Theoretically, BRA stabilize the occlusion and improve the function of the masticatory muscles, thereby decreasing abnormal activity
o They also protect the teeth incase of tooth grinding
o Patients may need to wear the splint for several weeks before a benefit is felt
o The splint should be worn at the time of parafunction

81
Q

What are the irreversible tx of TMJD

A

occlusal adjustment
surgery

82
Q

What are the different types of TMJ surgery

A

 Arthocentesis
 Arthroscopy
 Disc-repositioning surgery
 Disc repair/removal
 High condylar shave
 Total joint replacement

83
Q

What is disc displacement aka

A

internal derangement

84
Q

What is joint clicking due to

A

lack of coordinated movement between the condylar and the articular disc

85
Q

What happens normally in terms of coordination between the condyle and articular rdisc

compared to clicking

A

when the condyle moves forward around the eminence (when mouth is opened) the disc should move with it

86
Q

What happens when there is clicking (displacement)

A

Because of increased pressure inside the joint, the disc slips in front of the joint while the mouth is closed and so they find translation difficult because the disc is trapped in front of the joint and they have to manipulate the joint to slip the disc back in place and at this point they may hear the click

The condyle has to overcome the mechanical obstruction before full joint movement can be achieved
Clicks may occur on opening or closing and can be classified as early, middle or late

87
Q

What is the most common cause of clicking

A

anterior disc displacement with reduction

88
Q

What happens in anterior disc displacement with reduction

A

o Disc is initially displaced anteriorly by the condyle during opening until the disc reduction occurs

89
Q

What are the signs and symptoms of disc displacement

A

 Jaw tightness/locking
 Jaw movement is impaired for a short period of time until the disc reduces
 The mandible may initially deviate to the affected side before returning to the midline

90
Q

If anterior disc displacement + reduction is left untreated what can happen

A

may eventually progress to osteoarthritis

91
Q

What is tx of anterior disc displacement + reduction

A

 Counselling
 Limited mouth opening to avoid stretching disc
 Bite raising appliance
 Occasionally surgery
 If painless however, no tx required

92
Q

How does trismus from trauma occur

A

 Can occur after even minor traumatic events, will usually resolve spontaneously
 If no resolution after acute phase, may require physiotherapy, therabite, jaw screw

BDS4 Oral Surgery (15 decks)

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