TMJD Flashcards
Give differential diagnosis of tmj disorders
Infection/inflammatory - septic athritis, otitis media (leads to ankylosis)
Neoplasia (benign/malignant)
Drugs/degenerative (osteoarthritis)
Iatrogenic (Idiopathic condylar resorption, myofascial pain)
Congenital/developmental (condylar hypoplasia/aplasia, hyperplasia/ hemifacial microsomia)
Autoimmune (Rheumatoid, psoriatic, gout)
Trauma (fracture, effusion, dislocation)
Endocrine/metabolic
What are the causes of TMJD
Trauma (direct or indirect - whiplash)
Bruxism
Joint laxity
Stress
Important relevant history in arthromyalgia
Type of pain Location of pain Severity Triggering factor Aggravating factor Relieving factor Other comorbids- joint dz? Gout? Migraine? Spine problems? Fibromyalgia?
Specific findings
Muscle tenderness involving muscle of mastication
Associated with localized trigger points
Limited mouth opening or range of movement
With or without joint clicking
What are characters of internal derangements of tmj
Disc displacement with or without reduction
Perforation of disc/retrodiscal tissues
Degenerative changes in the disc and articulating surface
What are the changes that occur intraarticular in tmjd
Disc displacement (anterior>medial>anterolateral>other)
Chondromalacia (softening, furrowing, fibrillation & ulceration, crater formation & subchondral bone exposure)
Synovitis
(acute 1 - minimal vasodilation; no hyperemia
2- moderate vasodilation; early hyperemia
3- considerable vasodilation; moderate hyperemia
4- obliteration of vascular pattern; total hyperemia
Chronic -hyperplasia & tissue folds)
Wilkes classification of internal derangement
5 stages based on pain, mouth opening, disc position, anatomy
Investigations
OPG - screen for bony condylar changes
TMJ view open and close mouth - assess the position of condylar head in glenoid fossa in motion
MRI - to see internal derangements or the intraarticular soft tissue pathology
Ct scan - osseous pathology
Scintigraphy - bone activity, inflammation
Investigation finding
Mri - disc displacement, disc perforation, synovial inflammation,
Objectives of tx
Eliminate pain
Improve function
Stable occlusion
Treatment algorithm for TMJD or arthromyalgia WITH pain
- Nonsurgical conservative therapy: soft diet; medications; occlusal appliance; physiotherapy; stress reduction technique
- Arthrocentesis
- Arthroscopy
- Open joint surgery: disc repositioning (discoplasty)
What is nonsurgical management of tmjd
- soft diet
- medications
- nsaids - antiinflammatory & analgesia
- steroids - antiinflammation
- muscle relaxants - chlorobenzaprine 5mg tds
- antidepressants - TCA - amitriptyline
- anxiolytics - diazepam 5mg qid - oral appliance
- stabilization splint - hard acrylic splint of maxilla covering all dentition, flat nonguiding surface - doesnt prevent clenching and grinding
- repositioning splint - hard acrylic splint of maxilla with an inclined plane to guide the mandible anteriorly thereby recapturing an anteriorly displaced disk
- modified hawley retainer - hard acrylic splint with an anterior plate where 6 anterior teeth are in contact and producing an open bite at the posterior teeth - prevents grinding and clenching - physiotherapy - jaw exercise, heat pack, topical spray and stretch, massage.
- stress reduction technique
Treatment algorithm for TMJD with LOCKING
- Arthrocentesis
- Arthroscopy
- Open joint surgery (discoplasty/discectomy with or without replacement)
Arthrocentesis
Lysis and lavage the superior joint space
Indications of arthrocentesis
Acute/chronic trismus with anterior disc displacement
Chronic pain with anteriorly disc displacement that doesnt resolve with nonsurgical
Degenrative joint disease
Technique of arthrocentesis
Using 2 needles for inflow and outflow
Inflow: 10-2 point anterior to midtragus - inferior to canthotragal line
Outflow: 20-10 point anterior to midtragus - inferior to canthotragal line
Lavage with minimum 100ml Hartmanns/NS
Manipulate mouth opening to break the adhesions
Intraart injection: steroids/ hyalauronic acid/ morphine/ local anesthesia
Arthroscopy
Inserting scope for diagnostics or therapeutic purposes.
Diagnostics: anatomical landmarks to look at
Retrodiscal synovium - retrodiscal tissue
Posterior disc attachment
Disc
Articular eminence and glenoid fossa
Synovial drape
Therapeutic: Lysis and lavage (arthrocentesis) Biopsy Synovectomy Freeing the adhesions Releasing the lateral pterygoid Disc repositioning Intra-articular pharmacotherapy
Indications of arthroscopy
Disc derangements Osteoarthritis Rheumatoid arthritis Crystal-induced arthritis Synovial pseudotumors
Absolute contraindications of arthroscopy
Ankylosis
Advanced resorption of glenoid fossa (accidental perforation into middle cranial fossa)
Infection and malignant tumors
Relative contraindications
Risk for hemorrhage
Risk of infection
Fibrous ankylosis
Postoperative care of arthroscopy
Anaesthetic effect if involved facial nerve should be reassured
Postoperative analgesia
Antibiotic if infection risk is high (immunodeficiency/ prosthetic valves) if normal, no need a/b
Physiotherapy
complications of arthrocentesis/arthroscopy
hemoarthrosis - venous in origin (McCain suggested protocol - to position condyle to where the bleeding is for 5mins to act as pressure)
Extravasation (of fluid into surr tissue which may lead to extensive edema of upper airway)
Broken instruments;
Otologic complications: perforation to EAM, tympanic membrane, hemotympanum, partial dislocation of malleus, hearing loss (3 case reports),
Intracranial damage;
Perforation into middle cranial fossa
facial nerve or auriculotemporal nerve injury
Infection (rare and doesn’t necessarily indicates antibiotic)
Open joint surgery
Discoplasty - disc repositioning
Discectomy - removal of damaged disc
Disc replacement - interpositional grafts (temporalis fascia, cartilage)
preauricular approach to tmj
- skin along tragal line +/- temporal extension
- subcut tissue
- temporoparietal fascia (above ZA) and SMAS (below ZA) - STV and ATN above the fascia/ TB of FN below the fascia
- dissection of flap for anterior retraction:
above the ZA - superficial layer of temporalis fascia
below the ZA - avascular plane along the external auditory cartilage - incision above ZA on superficial layer of TF - begins at root of ZA just in front of tragus, extending anterosuperiorly
- fat tissue
- deep layer of TF
- periosteum at root of ZA
- lateral capsule of TMJ
Closure of tmj open surgery
Lateral capsule
Temporalis fascia
Subcut tissue
Skin using subcuticular
Which joint disease produces worsening pain with function?
Osteoarthritis
Which joint diseases has worse pain in the morning but improves over the day
Rheumatoid arthritis
What are clinical presentation of RA?
Bilateral involvement (unlike OA, or other gout dz which is usually unilat) Pain with limited range of movement Preauricular swelling Pain which is worse in morning which improves over course of the day Late presentations: - condylar resorption - class 2 malocclusion - AOB - ankylosis
Radiographic findings of RA
Bilateral involvement of the joint
Condylar flattening
Cortical erosion
Loss of ramus height
Presentation of Juvenile RA
<12 years Bilateral Flattening and erosion of radiograph Loss of ramus height Aperthognathia (AOB) Skeletal class 2 with bird face deformity Positive RF (20%) and ANA (60-80%)
What are lab tests for rheumatoid arthritis
Serological markers:
ACPAs (anti-citrullinated protein antibodies)
RF (rheumatoid factors)
ANAs (antinuclear antibodies)
HLA Dw5, DRw
ESR: to indicate/monitor disease progression or clinical course
Features of osteoarthritis
Narrowing of joint space
Cortical erosions
Osteophyte formation
Subchondral cysts
What is treatment of RA.
Disease management: NSAIDs, steroids, soft diet, physiotherapy, immunosuppressive drugs - referral to rheumatology
Structural defect mx: arthrocentesis/arthroscopy/open joint surgery, ogs
What are arthrotic changes in arthritis (OA)
Erosion
Sclerosis
Flattening
Reduced joint space
Management of OA
Conservative: soft diet, medications, occlusal splint, physiotherapy.
Surgical: removal of osteophytes and smoothening of erosions
(Only indicated if conservative mx not effective after 6 months)
What is Reiters syndrome
Inflammatory arthritis that develops from an infection else where in the body (cross reactivity)
Classic triad:
Arthritis (cannot climb)
Uveitis (cannot see)
Urethritis (cannot pee)
Labs:
RF negative
Is the posterior disc vascularized and innervated?
Yes.
As it continues to retrodiscal tissues that contains vessels and nerves
What is Eagle syndrome
Elongation of styloid process that causes pain in the neck
What is Idiopathic condylar resorption?
Bilateral symmetric progressive condylar resorption
Followed by stabilization without further loss of height down to sigmoid notch
Occuring in young teenage females at pubertal growth spurt
Presentation of ICR?
Mild symptoms of TMJD without restriction in function Thinning and flattening of the condyle Loss of posterior ramus height Anterior open bite Mandibular retrusion Class 2
Diagnosis of ICR is made based on
Bone scintigraphy (Technetium 99) to assess activity inflammation, resorption or stabilization of disease
Treatment controversy of ICR
Treatment to restore function, stable occlusion and aesthetic
- conservative tx with splints, medications and physiotherpay if symptomatic, and to stabilize progress of disease
- orthognathic surgery requiring BSSO to advance mandible once disease has been stabilized
- associated with an increase risk of relapse due to reactivation of ICR
- TMJ reconstruction/replacement is considered gold standard with complete removal of disease - controversial as to be too invasive surgery
Methods to ensure stabilization of ICR?
- Severity of AOB whether increasing or similar
- Dentals casts to allow comparisons from previous review dates
- Lateral cephalogram, able to assess the condyle and extension of skeletal discrepancy, able to measure post ramus height
- Opg to look at changes in the condylar flattening or erosion
- Bone scan with Technetium to look for activity of inflammation, growth or condylysis (destruction)
What are indications for TMJ reconstruction?
End stage joint disease of OA or RA (usually presents with severe pain and severe resorption) Adult ankylosis Severe ICR with total loss of condylar Neoplasm of TMJ requiring resection Avascular necrosis of the tmj
Contraindications of total joint replacement
Active infection Inadequate local bone Known allergy to TJR material (nickel, titanium) Pediatric (or still growing) Inability to under rehabilitation
Complications of Total joint replacement?
Failure of hardware
- breakage of component
- loosening or displacement of hardware
- wearing through of fossa material
- prosthesis does not fit
- fixation failure
Biologic
- infection
- immune response (allergy or foreign body reaction)
Operative related
- Nerve injury (facial nerve, ATN)
- otologic complications (hemotynpanum, perforation of EAC or tympanic membrane)
- bleeding (superficial temporal artery during flap approach; masseteric artery/internal maxillary artery during resection of condyle which is located 20mm below condylar head; pterygoid venous plexus, middle meningeal artery)
- intracranial injury (glenoid fossa thickness is 0.9mm) - rarely reported
Types of alloplastic joint prosthesis and their differences
- Prefabricated (stock prosthesis) - allows 1 stage procedure to resect and reconstruct
- Custom prosthesis - requires 2 stage procedure, resection - ct scan for custom joint fabrication - reconstruction
