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C M S 2 > TMJ Surgery > Flashcards

TMJ Surgery Flashcards

1
Q

What is the prevalence of TMJ clicking?

A

30% of population has clicking.

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2
Q

Is there a direct relationship between anatomy of joint/ or pathology of joint and TMJ symptoms?

A

*No direct relationship between anatomy of joint / or pathology of joint & TMJ symptoms.

  • Some pts may have radiological abnormalities but no symptoms.
  • Very low % have radiological abnormalities & symptoms. But doesn’t mean you would benefit from surgery.
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3
Q

What are the symptoms of TMJ?

A
  • Pain
  • Click
  • Crepitus (crunching in joint)
  • Limited opening
  • Closed lock (mouth is shut, can’t open far enough)
    o Open lock is trying to close but can’t close it.
  • Dislocation – yawning / hit in face causing jaw joint to be dislocated. Can’t close at all.
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4
Q

How does the TMJ work?

A
  • TMJ: Slides as it opens & also acts as ball & socket joint.
  • Disc slides backwards & forwards on top of condyle.
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5
Q

What is between the disc and condyle?

A

lower disc space.

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6
Q

What is between disc and glenoid fossa?

A

upper disc space

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7
Q

How does the joint dislocate?

A

To dislocate joint the condyle has to slide down the slope between glenoid fossa & glenoid eminence, round the corner and become stuck on glenoid eminence

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8
Q

Where is the External acoustic meatus located? And what is the clinical relevance?

A

– TMJ close to ear.

  • A lot of pts with TMJ also experience earache. Risk of damage to ear with TMJ surgery.
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9
Q

Which muscles are involved in jaw closure? (bigger than muscles that close jaw)

A
  • Temporalis
  • Medial pterygoid
  • Masseter
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10
Q

Which muscles are involved in jaw opening? (smaller and not as strong)

A
  • Lateral pterygoid
  • Myelohyoid
  • Suprahyoid muscles
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11
Q

What is the Ginglymo diathrodial joint?

A

Describes the TMJ joint:

Two joint spaces: ‘diathrodial’ – upper and lower joint space.

Disc held in space with fibres that come from the front & attach into lateral pterygoid muscle. At the back, attack to external acoustic meatus, back of glenoid fossa & back of condyle.

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12
Q

What is the nerve supply to TMJ?

A

Sensory Nerve Supply – branches of trigeminal nerve
* Auriculotemporal nerve
* Masseteric nerve

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13
Q

Describe what happens during TMJ Dislocation.

A

When condyle slides down the slope of glenoid fossa, and goes over articular eminence and gets stuck in front of the eminence.

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14
Q

During TMJ Dislocation, which muscles pull mandible up?
And then what happens to the joint when it’s dislocated?

A

Masseter, temporalis and medial pterygoid pull mandible up.

When joint is dislocated, they go into spasm and the upward pull keeps the condyle where it is and stops it getting back to original position.

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15
Q

During TMJ Dislocation, there is a risk of …….. with lower molar extractions.
How can this be solved?

A

Risk of SUBLUXATION with lower molar extractions- with apical pressure.

Can reposition into joint

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16
Q

Is dislocation a radiographic diagnosis or clinical diagnosis?

A

Clinical diagnosis - esp when pt can’t close mouth

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17
Q

How is a dislocated jaw treated?

A

Stand in front of pt, thumbs on back teeth / or retromolar pads. Ask pt to sit with back against the wall (if not in a dental chair)

Push down on mandible on both sides. Fingers under the chin & angle of mandible. Rotate the mandible backwards and down to reduce the dislocation.

If it doesn’t work -> A&E.

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18
Q

What causes recurrent dislocation?

A

ST around joint is loose, therefore nothing stopping the joint from opening too wide.

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19
Q

Recurrent dislocation is more common in which type of people and why?

A

More common in young people – flexible joints

20
Q

What is the main treatment for recurrent discloation?

A

Wire teeth together to prevent opening too wide. Stays on for 1 week to allow joint to get used to not opening & muscles to contract & weaken.

21
Q

Describe other 2 types of treatment for recurrent dislocation.
Hint:
-How to increase the size of eminence
-How to decrease the size of eminence

A
  • Increase size of eminence – makes it more difficult to dislocate. Wedge cut is made in eminence & a bone graft is placed into this e.g. from hip/ribs.
  • Decrease the size of eminence – easier for dislocated condyle to be reduced back into joint.
22
Q

The most common diagnosis in pts with TMD is…..

A

internal derangement of the TMJ

23
Q

What is the internal derangement of TMJ?

A

Disruption within the internal aspects of the TMJ in which there is a displacement of the disc from its normal functional relationship with the mandibular condyle and the articular portion of the temporal bone.

  • But MRI shows disk is displaced in 1/3 of people who have no symptoms.
24
Q

What is the classification used for internal derangement?

A

Wilkes Classification

25
Q

What is Stage I of Wilkes Classification of internal derangement?

A

I. Painless clicking = slight forward displacement of the disc

26
Q

What is Stage II of Wilkes Classification of internal derangement?

A

II. Occasional painful click, intermittent locking, headaches = beginning of deformity & thickening of posterior edge.

27
Q

What is Stage III of Wilkes Classification of internal derangement?

A

III. Frequent pain, joint tenderness, headaches, restricted motion = anterior disc displacement and significant deformity (of disc or joint).

28
Q

What is Stage IV of Wilkes Classification of internal derangement?

A

IV. Chronic pain, headaches, & restricted motion = degenerative changes, flattening of eminence, deformed condyle (on MRI)

29
Q

What is Stage V of Wilkes Classification of internal derangement?

A

V. Variable pain, crepitus, painful function = disc perforation, gross anatomical deformity

30
Q

Disc displacement with reduction is which Wilkes stage?

A

Wilkes stage I/II

31
Q

No clicking. Disc displacement without reduction is which Wilkes stage?

A

Wilkes stage III/IV

32
Q

What is clicking caused by?

A

disc moving backwards and forwards.

33
Q

Which stage of Wilkes do you get a click?

A

1 or 2 to get a click.

34
Q

Describe the progression of Internal Derangement.

A
  • Progression from Wilkes 1 to Wilkes 5 is not inevitable
  • 70% will resolve within 18 months
  • <10 with Class I will progress to Wilkes 5 (perforation of the disk) within 10 years
35
Q

Name the 4 MINIMALLY invasive surgical options for TMJ

A
  • Joint Injection with steroid
  • Muscle injection
  • Arthrocentesis
  • Arthroscopy
36
Q

List the open joint procedures for TMJ.

A
  • Disc repair/repositioning (meniscopexy)
  • Disc removal (meniscectomy)
  • Articular eminence/ zygomatic arch procedures
  • Joint reconstruction procedure
37
Q

What are the indications for joint injection with steroid?

A
  • Failed conservative management
  • Pain
  • Degenerative joint disease (arthritis)
38
Q

What are the indications for arthrocentesis? (joint wash out)

A
  • Failed conservative management
  • Pain
  • Closed lock
39
Q

What are the indications for arthroscopy?

A
  • Failed conservative management
  • Pain
  • Closed lock
40
Q

What are the complications of arthroscopy?

A

· Swelling
· Bruising
· Bleeding
· Pain
· No improvement
· Facial nerve damage
· Damage to ear canal
· Damage to middle ear

41
Q

What are the INVASIVE surgical options for TMJ?

A
  • Open joint surgery
  • Meniscopexy (move disc back)
  • Menisectomy (remove disk)
  • Smooth joint surfaces e.g. joint erosions or osteophytes
  • Gap arthroplasty (joint ankylosis so can put some tissue into this space to allow for opening)
  • TMJ replacement
42
Q

Give examples where TMJ replacement is indicated

A

e.g. grossly diseased joint e.g. arthritis, joint causing malocclusion.

43
Q

What are the complications of TMJ replacement?

A

o Facial nerve damage
o Infection
o Damage to ear canal
o Hearing loss
o Cerebrospinal fluid leak
o Failure of implant – microcracks in metal or plastic cup erosion. Will need replacement at some point.

44
Q

How can Physiotherapy work as a procedure for TMJ? And give an example of a device that can be used for this

A

activate machine to push teeth apart by spreading load over all teeth.

Example- TheraBite device replicating physiological movements.
E.g. jaw joint surgery, H&N radiotherapy resulting in trismus.

Or tongue depressers stacked over each other slowly over time. Puts pressure on anterior teeth so can damage if weak e.g. veneers, loose teeth etc.

45
Q

Name the other procedures for TMJ

A
  • Physiotherapy
  • Exercises
    -Psychological input

C M S 2 (29 decks)

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