TMJ surgery Flashcards
What symptoms highlight that surgical intervention may be needed?
Pain
Limited opening (if mechanical rather than muscle spasms)
Malocclusion
Dislocation
Facial asymmetry
What are the types of TMJ pain and their causes?
Acute = Trauma, acute disc displacement, or a tumour
Chronic = Osteoarthritis, inflammatory arthritidies, or a tumour
What causes limited opening?
Adhesions
Disc pathology
Ankylosis
Trauma
Tumour
Coronoid hyperplasia
What causes malocclusion/facial asymmetry
Trauma
Joint degeneration
Joint mass: Effusion tumour synovial chondromatosis
Ankylosis
Aplasia, hypoplasia, hyperplasia
How is pain investigated during the work up for surgery?
VAS
Pain diagram
Well localised pain that can be pointed to in the TMJ or generalised/referred
Functional pain
Limitations of movement
Joint noise and locking
Dietary modification (are they eating different food because of it?)
What are the key points to look for with clinical examination of TMJ?
Joint tenderness to palpation
Joint noises (unreliable but clicking and crepitus)
Pain on loading (contralateral TMJ to area of biting ipsilateral pain doesn’t mean anything)
Range of motion, deviation
Occlusion: Malocclusion, open bites, wear
What imaging can be used for TMD?
OPG is a screening tool not good for diagnostics
MRI (soft tissues)
CT scan (bone)
What could CT show about TMD?
Erosions of cortical outlines
Loss of joint space
Osteophytes
Subcortical cysts
Multidetector CT scan show disc position
What classification is used to know when patients should be treated with surgery?
Wilke’s classification
What are the stages of wilke’s classification?
Stage 1 = early with painless click (radiograph shows slight ADD but normal disc anatomy)
Stage 2 = Early intermediate. Occ painful clicking and transient locking (Slight ADD and early disc deformity)
Stage 3 = intermediate, Locking, restriction, frequent pain (ADD disc deformity)
Stage 4 = Locking, restriction, pain (ADD w/o R, disc deformity, bone canges)
Stage 5 = crepitus, chronic restriction, and dysfunction (disc deformity, perforation, flattening, osteophytes, subchondral cysts)
What are the signs and symptoms of MPD?
Diffuse poorly localised pain
Cyclic
Frequenly worse in the morning
Sleep disturbance
Bruxism
Tiredness, fatigue
Diffuse muscle tenderness and hypertopgy
Decreased range of motion
Joint noise
Wear facets
How is MPD managed?
Explanation
Home care
Meds
Occlusal appliance
PT
Psych mgmt
Botox
Problems resolve slowly over weeks-months
Frequently recurs
What are the symptoms of TMJ internal derangements?
Well localised TMJ pain
Continuous pain worse with function
Joint noise
Altered joint mechanics with deviation, intermittent locking, and closed lock
What are the symptoms of TMJ OA?
TMJ pain variable occuring at rest and with function
Morning stiffness
Crepitation +/- clicking
Occlusal changes
What are the treatment goals of TMJ surgery?
Reduce pain, inflammation, joint loading, and restore mobility.
Most patients will have resolution of symptoms with conservative treatment
What are the conservative treatments of TMD?
Explanation
Soft diet
Warm moist heat
NSAIDs, muscle relaxants
Occlusal aplpiances
What are the surgical procedures done for TMJ disorders?
Arthrocentesis
Arthroscopy
Open joint (Discopexy, discectomy, reconstruction)
What is arthrocentesis?
Simplest TMJ intervention consisting of:
Lavage, examination under anaesthetic, and insertion of medications.
The idea is to wash out the effusion while injecting medication into it.
How are patients managed post operatively following arthrocentesis?
Aggressive ROM exercises
NSAIDs
Occlusal appliance
Follow up
What are the indications for arthrocentesis?
Painful limited opening (closed lock (Acute or subacute non responsive to conservative management)
Osteoarthritis pain refractory to conservative measures
Inflammatory arthritis for pain management
Others such as hypermobility or trauma
What are the results of arthrocentesis like?
Results are good
What is arthroscopy?
Cameras inserted into the joint and surgery done through this.
What are the indications for arthroscopy?
Interanl derangement
Degenerative joint disease
Synovitis (inflamed synovium)
Painful hypermobility
Hypomobility caused by intrarticular adhesions
What kind of procedures would require open TMJ surgery?
Disc procedures
Fixation
Reshape (fossa, condyle)
Biopsy
Ankylosis
Replacements
How is the TMJ accessed during TMJ open surgery?
Incision (preauricular or behind the ear submandibular incision for lower half of ramus)
What are the indications of open TMJ surgery?
Significant TMJ pain and/or dysfunction
Only when non-surgical treatment has failed
Imaging evidence of disease
How can open TMJ surgery repair the disc?
Reposition
Repair
Removal
Replacement (Total TMJ replacement)
What are the indications for TMJ replacement?
Degenerative arthritidies (OA and RA)
Fibrous/bony ankylosis
Failed alloplastic reconstruction
Loss of vertical mandibular height and/or occlusal relationship
Failed previous surgeries
What factors can cause loss of vertical mandibular height and affect occlusal relationship?
Condylar resorption
Trauma
Developmental abnormality
Pathology
