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NYU Review > TMJ sx > Flashcards

TMJ sx Flashcards

McCain

1
Q

What two pieces of information are needed to treat TMJ disorders?

A

Etiology of Disorder and Classifcation of disorder

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2
Q

What are 5 etiologies of TMD?

A
  1. Parafunction
  2. Dentofacial deformities/malocclusions
  3. Direct macrotrauma to jaw
  4. Indirect macrotrauma to jaw (acceleration/deceleration injury that caused rapid jaw movement)
  5. Systemic disease
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3
Q

Synovial joint disease of the TMJ can be broken down to two categories? what are they and their sub categories?

A

Inflammatory and Non inflammatory

Inflammatory can be broken down to primary and secondary arthritis.

Primary arthritis is immune based (RA, JA)

Secondary Arthritis is reactive (trauma, infection)

noninflammatory = internal derangement, OA)

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4
Q

Crepitation of the joint indicates?

A

Perforation of the disc

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5
Q

What is normal MIO?

A

35-55mm

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6
Q

What is the McCain sign/test? (joint loading)

A

take two tongue blades and have bite on cuspids, right and left side.

If patient has pain it is joint pain (not muscular).

biting causes condyle to compress retrodiscal tissue, which if inflamed will have pain.

Minimal pain if already perforated

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7
Q

Preoperative if is important to do what examination?

A

Otoscopic exam -eval for wax and tympanic membrane issues (pull ear up and back)

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8
Q

How is a panoramic useful in TMJ problems?

A

can evaluate teeth relationships and bony relationship

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9
Q

What is first line of tx for TMJ disorders?

A

Conservative treatment

  • soft diet/rest
  • NSAIDs
  • Muscle relaxants (Baclofen = peripheral acting) (Flexeril/cycloebenzaprine = central acting)
  • tx parafunctional habits (biteguard/occlusal splint)- ALL PTS get a SPLINT except those with minimal opening
  • consider PT
  • consider occlusion
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10
Q

Are COX-1 or COX-2 enzymes more likely to cause inflammation? What inhibits this enzyme?

A

COX-2

Celebrex, Mobic (low dose)

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11
Q

When would you get serology testing for TMJ pts?

A

Condylar resorption

Rheumatoid factor, ANA, CCP, HLa-B27, Vit. D, 17B estradiol should be tested

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12
Q

How do occlusal splints work?

A

positions teeth so condyle doesn’t rest on retrodiscal tissue. This decreases inflammation and allows disc to reduce.

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13
Q

MRI; T1 vs t2 whats the difference?

A

T1 = water is black - shows anatomy, disc, position of disc, and morphology

T2 = water is white - shows joint effusions

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14
Q

What is an internal derangement?

A

localized mechanical faults in a synovial joint that interferes with smooth action

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15
Q

Define Wilkes I

A

Wilkes I = Click with no pain, minimal displacement and morphologic changes

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16
Q

Define Wilkes II

A

Wilkes II = Click with Pain, with minimal positional changes ( ADD) and minimal morphologic changes

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17
Q

Define Wilkes III

A

Wilkes III = Click ( maybe in past) with pain. Closed lock and limited range of motion.

Morphologic and positional changes noted - chronic ADD and adhesion formation

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18
Q

Define Wilkes IV

A

Wilkes IV = No click - Chronic, episodic pain with bony changes and ADD

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19
Q

Define Wilkes V

A

Wilkes V = crepitus limited ROM, likely with perforation and bony changes

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20
Q

What are numbers needed to know for arthrocentesis?

A

along holmlund-Hellsing line horizontal (tragus to eye canthus)

10 mm anterior to mid tragus and 2mm below line = entrance point to glenoid fossa

-Insufflation with 3-5 mL

20 mm anterior to mid tragus and 10mm inferior to line is the site of eminence

Center of superior joint space is 25mm deep

Requires 200-200 mm of fluid irrigation

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21
Q

Level I Arthroscopy is defined as?

A

Diagnostic single puncture arthroscopy!

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22
Q

What is the pertinent anatomy of arthroscopy?

A

Vasculature -

  • traveling inferior to superior just anterior to ear is the superficial temporary Art. and V. (posterior to puncture site)
  • Travelling posterior to anterior are the Transverse Facial Art. and V.

Nerve = Auricolotemporal nerve travels with superficial artery and vein

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23
Q

If your scope or needle travels deeper than 25mm what complications are you likely to run into?

A

damage to tympanic membrane and ossicles of middle ear

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24
Q

Sequence of level 1 arthroscopy?

A

Exam under anesthesia (mark patient and open patient)

Insufflation (3-5 mL)

Puncture

Lavage (200-350 mL) - requires exit port

Diagnostic sweep
- looking for synovitis, adhesions/ plica formations, and chondromalacia

Lysis of adhesion

Deposit medications

Manipulate jaw in ROM under GA

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25
Q

What are the 7 points of interest within the superior joint space that should be examined on arthroscopy?

A
  1. Medial synovial drape - vertical striae is normal ( white/avascular) medial posterior portion of space.
  2. Pterygoid shadow - medial anterior
  3. Retrodiscal synovium = posterior space
  4. Posterior slope of glenoid fossa
  5. Articular disc (posteriorly)
  6. Intermediate zone (middle)
  7. Anterior recess - vascular hump contains temporal vessel
26
Q

What is synovitis?

A

Inflammation of the synovial lining that lead to effusion then necrosis and scarring with adhesions and stenosis.

Worst case is fibrous anklyosis

Inflammation is caused by triggering event

27
Q

what are 3 theories of synovitis triggering events?

A
  1. Direct mechanical model - leads to physical disruption and ischemia of normal cell population causing necrosis
  2. Hypoxia reperfusion = loading of joint causes elevated local hydrostatic pressure causing hypoxia which then reperfuses on opening rapidly causing increase in O2 free radicals causing scarring and necrosis
  3. Neurogenic Inflammation = peripheral nerve irritation causes release of neuropeptide Substance P which releases cytokines causing inflammation and necrosis/scarring
28
Q

Synovitis presentation

A
  1. petechiae
  2. blood vessels
  3. pan synovitis = sloughing of tissue
  4. adhesions
  5. Chondromalacia = crystalline formation
29
Q

What medications can be placed in joint?

A

HA = hyaluronic acid = lubrication

Steroids = decrease inflammation

Sclerosing agents (sotradecol)

30
Q

Do patients need post op PT?

A

yes - can be at home or with PT

31
Q

What is level II arthroscopy? Sequence?

A

Operative Arthroscopy double puncture

Sequence remains the same - exam under GA, insufflation, puncture, lavage, diagnostic sweep…

level two = measurement of first scope depth with second puncture at anteriro recess of superior joint space.

Once second puncture is in place you can perform operative procedures with direct visualization from original puncture.

complete operation, add medications, and manipulate jaw under GA

32
Q

how do you place your second puncture?

A

First puncture scope is directed to anterior recess of superior joint space under direct visualization.

At this point you measure your cannula then place a needle which can be visualized then add second cannula - this is your device channel

33
Q

What is level III arthroscopy?

A

Discopexy - triple puncture

34
Q

complications of arthroscopy?

A

CN VII palsy

infection

hearing loss

bleeding-always have consent for open

facial scarring

auriculotemporal paresthesia

occlusion changes

puncture into brain cerebrum/through glenoid fossa (very thin bone!)

puncture into middle ear/ossicles

puncture through medial aspect of capsule

35
Q

What are 3 open approaches to the TMJ?

A

Preauricular

Endaural

Posterior Auricular-not common

36
Q

how does a MITEK anchor work?

A

Mitek is placed in posteior pole of the condyle .

Disc is repositioned

Sutures from mitek to disc to hold in position

37
Q

Mandibular dislocation treatment options

?

A

Eminectomy+/-arthroplasty

can do open or arthroscopically

sclerosing agents via arthroscopy = chemical contracture (sotradecol) can also use cautery and laser on retrodiscal tissue

Patient is kept in elastics ( orthodontic brackets) to keep in class I while tissue scars (6-8 weeks)

38
Q

What is synovial chondromatosis?

A

Small radioopacities within the joint space

noninflammatory, but affects function

can cause erosion into cranial base as it is aggressive

39
Q

how do you treat synovial chondromatosis?

A

Open procedure and remove all loose bodies. Debride joint thoroughly.

40
Q

Indications for discectomy?

A

failed arthroscopy

disc cannot be preserved due to deformity or perforation

41
Q

Interpositional grafts?

A

Fat graft, temporalis, alloplastic, skin, ear cartilage, temporary silastic

42
Q

Disc anatomy

A

Anterior band = attached to lateral pterygoid muscle

Intermediate band = thinnest zone, point of contact with condylar head

Posteior band= thickest are

Bilaminar zone = dorsal attachment

43
Q

Postoperative management of Open discopexy?

A

PT

NSAID and muscle relaxants

Bite split and soft diet

Remove silastic implant if used at 8 weeks or sooner if crepitus occurs

44
Q

If condylar resorption is noted on imaging (pan) what should you do?

A

Get blood work/serologies!

Pain may be on nonresorbed side due to burnout

45
Q

Success of TJR operations decreases if patient has had __ prior open TMJ surgeries??

A

three prior open TMJ procedures due to scarring

46
Q

What should you test for prior to TMJ alloplastic replacements?

A

Metal allergy - allergist workup

Nickel is common metal

47
Q

The condylar head of the TMJ concepts custom replacement must sit wear in the fossa?

A

middle of posterior wall/lip

48
Q

Indications for TJR?

A

Refractory inflammatory arthritis

Recurrent fibrous or bony ankylosis

failed alloplastic or tissue TMJ reconstruction

Loss of vertical mandibular height or VDO from trauma, bone resorption, developmental abnormality, pathology

49
Q

What is the approach/access for TJR?

A
  1. preauricular and submanidbualr/retromandibular
  2. condylectomy +/- coronoidectomy ( gap arthroplasty)
  3. Place patient into IMF
  4. try in and secure implants and verify occlusion (fossa first for tryin, then condyle, then both before securing)
  5. fat graft around implants
50
Q

when is fat grafting absolutely indicated?

A

in patients that demonstrate heterotropic bone formation.

some argue its always needed (wolford)

51
Q

TJR post op recommendations?

A

Guiding elastics (heavy for 4-5 days) after surgery to prevent dislocation.

Analgesics for 2-4 weeks

PT- too much can open up hematomas

Prophylactic ABX for 2 years or for life

52
Q

When are autogenous TJR indicated?

A

children and Idiopathic condylar resorption

53
Q

what is gold standard for autogenous TJR?

A

Costochondral graft harvest

secured with screws

post op is soft diet for 3-6 months

MMF for 1-4 weeks

gentle PT

54
Q

Common complications to rib grafting?

A

Pneumothorax

rib fracture

ankylosis of joint!

rib resorption in joint space

limited opening

55
Q

Causes of condylar resorption?

A

Inflammatory arhtitis, Joint compression, trauma, OA, hormonal imbalance

all these can all produce inflammation

Inflammation that releases cytokines

Cytokines induce osteoclasts that resorb bone

56
Q

Importnat cytokines in TMJ resorption?

A

RANKL, IL-6, TNF-A

57
Q

What enzymes do Osteoclasts produce that resorb bone?
What activates these enzymes?
What regulated theses enzymes?

A

MMP’s = matrix metalloproteinases

Activated by cytokines and free radicals and cellular stress (inflammation and compression/bruxism)
Regulated by Vitamin D, estradiol (female susceptibility) , osteoprogerin

58
Q

What medications can be used to combat primary arthritic cases?

A

TNF alpha inhibitors including etanercept (enbrel), infliximab (remicade), adalimumab (humira)

these can increase risk for infection, TB, lymphoma, leukemia, and demyelinating diseases

59
Q

what antibiotics can inhibit MMPs?

A

Tetracycline and Doxycycline

60
Q

In TJR replacements, what vasculature is on the medial of the condyle?

what may be considered regarding this?

A

Internal maxillary Artery

consider CTA, possible preop embolization with ICU overnight stay

61
Q

Whats the difference between 1 stage and 2 stage TJR?

A

1 stage = implants placed immediately

2 stage = gap arthroplasty, then allow healing and workup, then second surgery to place implants

NYU Review (8 decks)

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