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OMFS > TMJD > Flashcards

TMJD Flashcards

1
Q

Give differential diagnosis of tmj disorders

A

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

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2
Q

What are the causes of TMJD

A

Trauma (direct or indirect - whiplash)
Bruxism
Joint laxity
Stress

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3
Q

Important relevant history in arthromyalgia

A 
Type of pain
Location of pain
Severity
Triggering factor
Aggravating factor
Relieving factor
Other comorbids- joint dz? Gout? Migraine? Spine problems? Fibromyalgia?
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4
Q

Specific findings

A

Muscle tenderness involving muscle of mastication
Associated with localized trigger points
Limited mouth opening or range of movement
With or without joint clicking

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5
Q

What are characters of internal derangements of tmj

A

Disc displacement with or without reduction
Perforation of disc/retrodiscal tissues
Degenerative changes in the disc and articulating surface

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6
Q

What are the changes that occur intraarticular in tmjd

A

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)

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7
Q

Wilkes classification of internal derangement

A

5 stages based on pain, mouth opening, disc position, anatomy

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8
Q

Investigations

A

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

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9
Q

Investigation finding

A

Mri - disc displacement, disc perforation, synovial inflammation,

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10
Q

Objectives of tx

A

Eliminate pain
Improve function
Stable occlusion

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11
Q

Treatment algorithm for TMJD or arthromyalgia WITH pain

A
  1. Nonsurgical conservative therapy: soft diet; medications; occlusal appliance; physiotherapy; stress reduction technique
  2. Arthrocentesis
  3. Arthroscopy
  4. Open joint surgery: disc repositioning (discoplasty)
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12
Q

What is nonsurgical management of tmjd

A
  1. soft diet
  2. medications
    - nsaids - antiinflammatory & analgesia
    - steroids - antiinflammation
    - muscle relaxants - chlorobenzaprine 5mg tds
    - antidepressants - TCA - amitriptyline
    - anxiolytics - diazepam 5mg qid
  3. 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
  4. physiotherapy - jaw exercise, heat pack, topical spray and stretch, massage.
  5. stress reduction technique
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13
Q

Treatment algorithm for TMJD with LOCKING

A
  1. Arthrocentesis
  2. Arthroscopy
  3. Open joint surgery (discoplasty/discectomy with or without replacement)
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14
Q

Arthrocentesis

A

Lysis and lavage the superior joint space

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15
Q

Indications of arthrocentesis

A

Acute/chronic trismus with anterior disc displacement
Chronic pain with anteriorly disc displacement that doesnt resolve with nonsurgical
Degenrative joint disease

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16
Q

Technique of arthrocentesis

A

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

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17
Q

Arthroscopy

A

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
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18
Q

Indications of arthroscopy

A 
Disc derangements
Osteoarthritis
Rheumatoid arthritis
Crystal-induced arthritis
Synovial pseudotumors
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19
Q

Absolute contraindications of arthroscopy

A

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

20
Q

Postoperative care of arthroscopy

A

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

21
Q

complications of arthrocentesis/arthroscopy

A

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)

22
Q

Open joint surgery

A

Discoplasty - disc repositioning
Discectomy - removal of damaged disc
Disc replacement - interpositional grafts (temporalis fascia, cartilage)

23
Q

preauricular approach to tmj

A
  1. skin along tragal line +/- temporal extension
  2. subcut tissue
  3. temporoparietal fascia (above ZA) and SMAS (below ZA) - STV and ATN above the fascia/ TB of FN below the fascia
  4. dissection of flap for anterior retraction:
    above the ZA - superficial layer of temporalis fascia
    below the ZA - avascular plane along the external auditory cartilage
  5. incision above ZA on superficial layer of TF - begins at root of ZA just in front of tragus, extending anterosuperiorly
  6. fat tissue
  7. deep layer of TF
  8. periosteum at root of ZA
  9. lateral capsule of TMJ
24
Q

Closure of tmj open surgery

A

Lateral capsule
Temporalis fascia
Subcut tissue
Skin using subcuticular

25
Q

Which joint disease produces worsening pain with function?

A

Osteoarthritis

26
Q

Which joint diseases has worse pain in the morning but improves over the day

A

Rheumatoid arthritis

27
Q

What are clinical presentation of RA?

A 
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
28
Q

Radiographic findings of RA

A

Bilateral involvement of the joint
Condylar flattening
Cortical erosion
Loss of ramus height

29
Q

Presentation of Juvenile RA

A 
<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%)
30
Q

What are lab tests for rheumatoid arthritis

A

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

31
Q

Features of osteoarthritis

A

Narrowing of joint space
Cortical erosions
Osteophyte formation
Subchondral cysts

32
Q

What is treatment of RA.

A

Disease management: NSAIDs, steroids, soft diet, physiotherapy, immunosuppressive drugs - referral to rheumatology
Structural defect mx: arthrocentesis/arthroscopy/open joint surgery, ogs

33
Q

What are arthrotic changes in arthritis (OA)

A

Erosion
Sclerosis
Flattening
Reduced joint space

34
Q

Management of OA

A

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)

35
Q

What is Reiters syndrome

A

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

36
Q

Is the posterior disc vascularized and innervated?

A

Yes.

As it continues to retrodiscal tissues that contains vessels and nerves

37
Q

What is Eagle syndrome

A

Elongation of styloid process that causes pain in the neck

38
Q

What is Idiopathic condylar resorption?

A

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

39
Q

Presentation of ICR?

A 
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
40
Q

Diagnosis of ICR is made based on

A

Bone scintigraphy (Technetium 99) to assess activity inflammation, resorption or stabilization of disease

41
Q

Treatment controversy of ICR

A

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
42
Q

Methods to ensure stabilization of ICR?

A
  1. Severity of AOB whether increasing or similar
  2. Dentals casts to allow comparisons from previous review dates
  3. Lateral cephalogram, able to assess the condyle and extension of skeletal discrepancy, able to measure post ramus height
  4. Opg to look at changes in the condylar flattening or erosion
  5. Bone scan with Technetium to look for activity of inflammation, growth or condylysis (destruction)
43
Q

What are indications for TMJ reconstruction?

A 
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
44
Q

Contraindications of total joint replacement

A 
Active infection
Inadequate local bone 
Known allergy to TJR material (nickel, titanium)
Pediatric (or still growing) 
Inability to under rehabilitation
45
Q

Complications of Total joint replacement?

A

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
46
Q

Types of alloplastic joint prosthesis and their differences

A
  1. Prefabricated (stock prosthesis) - allows 1 stage procedure to resect and reconstruct
  2. Custom prosthesis - requires 2 stage procedure, resection - ct scan for custom joint fabrication - reconstruction

OMFS (54 decks)

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