TEMPOROMANDIBULAR DISORDERS
PRESENTED BY: Dr. MADAAN
ANATOMY OF TMJ Definition: It is a synovial joint of bicondylar variety. (CRANIOMANDIBULAR ARTICULATION) Also called the GINGLYMODIARTHRODIAL JOINT. Articular surfaces : 2 articular surfaces
upper Roof: 2 parts of temporal bone
Floor: superior surface of disc
lower Roof: inferior surface of disc
Articular eminence
Anterior part of mandibular fossa
Floor: Articulating surface of the mandibular condyle
ARTICULAR DISC It is an oval fibrous plate that divides the joint into an upper & lower compartment. Also referred to as FIBROCARTILAGE Concavo-convex superior surface and a concave inferior surface.
LIGAMENTS
FIBROUS CAPSULE: Attached above to the articular eminence & the squamotympanic fissure below to the neck of the condyle.
LATERAL LIGAMENT: (temporo mandibular ligament) Fibers are directed backwards and downwards. Attached above to the articular tubercle & below to the posterolateral aspect of the neck of the mandible.
SPHENO MANDIBULAR LIGAMENT: Attached to supine of Sphenoid & inferior to the lingula of the mandible
STYLO MANDIBULAR LIGAMENT: Attached above to the Lateral surface Of the styloid process & below to the angle & posterior border of ramus of the mandible
BLOOD SUPPLY
NERVE SUPPLY
MOVEMENTS: PROTRACTION OF MANDIBLE: The articular disc glides forwards over the upper articular surface, the head of the mandible moving with it. RETRACTION OF MANDIBLE : Reversal of protraction SLIGHT OPENING OF THE MOUTH: The head of the mandible moves on the undersurface of the disc like a hinge.
WIDE OPENING OF THE MOUTH : Hinge like movement followed by gliding of the disc & head of mandible. LATERAL MOVEMENTS: Head of one side glides forwards along with disc but head of the opposite side merely rotates on vertical axis.
BORDER MOVEMENTS Maximum movement of mandible relative to a single point on mandible during all possible extreme movements CONTACT MOVEMENTS Produced during gliding when maxillary & mandibular teeth are in contact with each other FREE MOVEMENTS In this teeth do not come into contact with each other
PROTRUSION Forward movement of mandible Muscles involved:1. Lateral pterygoid 2. medial pterygoid Muscle involvement is bilateral
RETRACTION Backward movement of mandible Muscles involved:1. Temporalis (post. fibres) 2. Digastric (post. belly) Bilateral involvement
DEPRESSION Downward movement of mandible Causes opening of mouth Muscles involved:1.Lateral pterygoid 2.Digastric(ant.belly) 3.Geniohyoid 4.Mylohyoid Muscle involvement is bilateral
ELEVATION Upward movement of mandible Causes closing of mouth Muscles involved:1. Masseter 2. Temporalis 3. Medial pterygoid During this closure movement, head is retracted before elevation
ELEVATION R E T R A C T I O N
TEMPORALIS
DIGASTRIC GENIOHYOID
MASSETER MEDIAL PTERYGOID
LATERALPTERYGOID
MYLOHYOID
DEPRESSION
P R O T R U S I O N
TMJ DISORDERS ETIOLOGY :Some factors proposed are: 1. Parafunctional habits 2. Emotional distress 3. Acute trauma from blows or imparts 4. Trauma from hyperextension 5. Instability of maxillomandibular relationships 6. Laxity of the joints 7. Comorbidity of other rheumatic or musculoskeletal disorders. 8. Poor general health and unhealthy lifestyle.
DIAGNOSTIC CLASSIFICATION Diagnostic category
Diagnosis
Cranial bones (including the mandible )
Congenital and developmental disorders: aplasia, hyperplasia, hypoplasia,and dysplasia Acquired disorders :(neoplasia, fracture)
DIAGNOSTIC CLASSIFICATION Diagnostic category Temporomandibular joint disorders
Diagnosis Deviation in form Disk displacement with reduction , without reduction) Dislocation Inflammatory conditions (synovitis,capsulitis) Arthritides (osteoartheritis, osteoarthrosis) Ankylosis & Neoplasia
DIAGNOSTIC CLASSIFICATION Diagnostic category
Diagnosis
Masticatory muscle disorder
Myofacial
pain
Myostitis Spasm Protective
splinting Contracture
ASSESSMENT Diagnostic assessment can be done using the following aids: 1. History 2. Physical examination 3. Range of mandibular movement 4. Palpation of masticatory movements 5. Palpation of cervical muscles 6. Palpation of TMJ 7. Assessment of parafuntional habits
8. Diagnostic imaging 9. Diagnostic LA nerve blocks
MYOFASCIAL PAIN OF MASTICATORY MUSCLES Also called, Masticatory myalgesia syndrome TMJ pain dysfunction syndrome
Etiology:
Masticatory muscle spasm Muscle spasm is because of : - Muscular Overextension - Muscular Over contraction - Muscle Fatigue
Chronic oral habits e.g. : grinding or clenching of teeth
Clinical features
1. 2. 3. 4.
Age : usually below 40 years Sex : females more than males Cardinal signs and symptoms : Pain Muscle tenderness Clicking noise in TMJ Limitation of jaw motion with deviation on opening
TRIGGER POINT THERAPY
It has used two modalities :
The cooling of skin over the involved muscle and stretching
The direct injection of LA into the muscle.
INTRACAPSULAR DISORDERS : ARTICULAR DISK DISORDER DEFINATION :Articular disk displacement (ADD) is an abnormal relationship between the : -the disk -the mandibular condyle -and articular eminence, resulting from the stretching or tearing of the attachment of the disk of the condyle and the glenoid fossa.
ETIOLOGY Trauma Bruxism
Clinical features ADD is divided into stages on the basis of signs and symptoms combined with the results of imaging studies : 1. 2. 3.
Anterior disk displacement with reduction ADD with intermittent locking ADD without reduction (closed lock)
ADD WITH REDUCTION (CLICKING JOINT) Due to loosening of articular disk because of : Elongation or tearing of restraining ligaments & has moved from its normal position on the top of the condyle. Chief complaint : Pain during mandibular movement. Pain is most noticeable at the time of a click.
ADD WITHOUT REDUCTION (CLOSED LOCK) Detected more frequently in patients with clicking joints that progress to intermittent brief locking and then permanent locking. The limited mandibular opening occurs when disk interferes with the normal translation of the condyle along the glenoid fossa. Limited lateral movement Pain
POSTERIOR DISK DISPLACEMENT
2. 3. 4. 5.
Described as the condyle slipping over the anterior rim of the disk during opening with the disk being caught and brought back ward in an abnormal relation to the condyle when the mouth is closed. c/f : 1. sudden inability to bring the upper and lower teeth together in maximal occlusion, Pain Displacement forward of the mandible on the affected side. Restricted lateral movements on affected side No restriction of mouth opening
MANAGEMENT
Recommended treatments for symptomatic ADD include - splint therapy -Manual manipulation & other forms of physical therapy -Anti-inflammatory drugs -Arthrocentesis -Arthroscopic lysis & lavage -Arthroplasty -Vertical ramus osteotomy
ADD WITH REDUCTION (CLICKING JOINT)
Flat plane stabilization splints
Anterior repositioning splint
ADD WITHOUT REDUCTION (CLOSED LOCK) Nonsurgical and surgical Nonsurgical : 1. Manual manipulation 2. Exercise program 3. Flat plane occlusal stabalization appliance 4. Anti-inflammatory drugs Surgical : 1. Arthrocentesis 2. Arthroscopy
DEGENERATIVE JOINT DISEAES (OSTEOARTHRITIS) It is primarily a disorder of articular cartilage and subchondral bone, with secondary inflammation of the synovial membrane. CLINICAL FEATURES Incidence increases with age Inflammation and joint effusions Clicking, snapping or unilateral pain over the condyle occurs Crepitus Limitation of opening Destruction of disc may also occur.
RADIOGRAPHIC FEATURES Narrowing of the joint space, irregular joint space, flattening of the articular surfaces, osteophytic formation, anterior lipping of the condyle, and the presence of Ely’s cysts.
Treatment Conservative therapy includes Nonsteroidal anti-inflammatory medications; Heat ; soft diet; rest ; and occlusal splints treat myofascial pain or meniscal defects. Intra-articular steroids
Synovial Chondromatosis CHONDROMETAPLASIA Synovial chondromatosis (SC) is an uncommon benign disorder characterized by the presence of multiple cartilagenous nodules of the synovial membrane that break, off resulting in clusters of free-floating loose calcified bodies in the joint. It is theorized that SC originates from embryonic mesenchymal remnants of the subintimal layer of the synovium that become metaplastic, calcify, and break off into the joint space
CLINICAL MANIFESTATIONS Slow progressive swelling in the pretragus region, Pain , and limitation of mandibular movement TMJ clicking, locking, crepitus, and occlusal changes Intracranial extension may lead to neurologic deficits such as facial nerve paralysis.
TREATMENT Treatment should be conservative and consist of removal of the mass of loose bodies. This may be done arthroscopically when only a small lesion is present, but arthrotomy is required for larger lesions.
Rheumatoid Arthritis The disease process starts as a vasculitis of the synovial membrane. It progresses to chronic inflammation marked by an intense round cell infiltrate and subsequent formation of granulation tissue. The cellular infiltrate spreads from the articular surfaces eventually to cause an erosion of the underlying bone.
CLINICAL MANIFESTATIONS
The TMJs are usually bilaterally involved in RA. limitation of mandibular opening and joint pain. Pain is usually associated with the early acute phases of the disease but is not a common complaint in later stages. Other symptoms often noted include morning stiffness, joint sounds, and tenderness and swelling over the joint area.
TREATMENT
Flat plane occlusal appliance may be helpful, particularly if parafunctional habits are exacerbating the symptoms. An exercise program to increase mandibular movement should be instituted as soon as possible after the acute symptoms subside. When patients have severe symptoms, the use of intra-articular steroids should be considered.
Surgical treatment of the joints including placement of prosthetic joints, is indicated in patients who have severe functional impairment or intractable pain not successfully managed by other means.
Psoriatic Arthritis Psoriatic arthritis (PA) is an erosive polyarthritis occurring in patients with a negative rheumatoid factor who have psoriatic skin lesions.251 The skin lesions precede the joint involvement by several years.
CLINICAL MANIFESTATIONS The symptoms of PA of the TMJ are similar to those noted in RA Radiographic findings: show erosion of the condyle and glenoid fossae rather than proliferation.
Treatment physical therapy and NSAIDS Immunosuppressive drugs, Only when there is intractable TMJ pain or disabling limitation of mandibular movement is surgery indicated. Arthroplasty or condylectomy with placement of costochondral grafts has been performed successfully.
Septic Arthritis Septic arthritis of the TMJ most commonly occurs in patients with previously existing joint disease such as rheumatoid arthritis, or underlying medical disorders (particularly diabetes). Patients receiving immunosuppressive drugs or long term corticosteroids also have an increased incidence of septic arthritis. Gonococci are the primary blood borne agents causing septic arthritis in a previously normal TMJ while Staphylococcus aureus is the most common organism involved in previously arthritic joints
CLINICAL MANIFESTATIONS Trismus Deviation of the mandible to the affected side, Severe pain on movement, An inability to occlude the teeth, owing to the presence of inflammation in the joint space. Examination reveals redness and swelling in the region of the involved joint. The swelling may be fluctuant and extend beyond the region of the joint. Large tender cervical lymph nodes are frequently observed on the side of the infection; TREATMENT Treatment of septic arthritis of the TMJ consists of surgical drainage, joint irrigation, and 4 to 6 weeks of antibiotics.
DEVELOPMENTAL DISTURBANCES
Include a) aplasia of mandibular condyle b) hypoplasia of mandibular condyle c) hyperplasia of mand condyle
APLASIA Mandibular condyle fails to develop Unilateral or bilateral disease
Clinical features Defective or absent external ear Underdeveloped mand ramus or macrostomia In unilateral aplasia -Facial asymmetry occurs -Both occlusion & mastication altered -Mand. shift towards affected side In bilateral cases mand. shift is not present
TREATMENT Osteoplasty Malocclusion corrected by orthodontic appliances Cosmetic surgery( for facial deformity)
HYPOPLASIA Underdeveloped or defective formation of condyle It may be congenital or acquired CLINICAL FEATURES: Facial asymmetry in unilateral cases In mild disturbance there is slight mandibular shifting from midline
TREATMENT
Cartilage or bone transplants preceded by osteotomy
HYPERPLASIA Unilateral enlargement of condyle. ETIOLOGY Mild chronic inflammation
CLINICAL FEATURES Unilateral slowly progressive elongation of face. Deviation of chin away from affected side. Severe Malocclusion occurs
TREATMENT Resection of condyle
TRAUMATIC DISTURBANCES Include a) Luxation & subluxation b) Ankylosis c) Fractures of condyle
LUXATION & SUBLUXATION
Dislocation occurs when head of condyle moves anteriorly into such a position that it cannot be returned voluntarily to its normal position.
ETIOLOGY Traumatic injury Yawning or opening the mouth too widely CLINICAL FEATURES Sudden locking & immobilization of jaws when mouth is opened. Mouth cannot be closed
TREATMENT Relaxation of muscles Moving the mandible to its position by exerting inferior & post. pressure of thumbs in mandibular molar areas.
FRACTURES OF CONDYLE ETIOLOGY Traumatic injury CLINICAL FEATURES Limitation of motion Pain & swelling over involved condyle
TREATMENT
ANKYLOSIS Hypomobility ETIOLOGY Traumatic injury Infections in & about the joints CLINICAL FEATURES Patients may not able to open the mouth to appreciable extent. Facial deformity occurs TREATMENT Surgical
NEOPLASTIC DISTURBANCES Neoplasms or tumor like growths benign or malignant may involved TMJ. Some tumors may originate from condyle or from joint capsule. Metastatic tumors have also been reported to involve TMJ.
EXTRAARTICULAR DISTURBANCES Sinusitis & middle ear disease often caused pain in joint. Other conditions like cellulitis, odontalgia, neuritis of trigeminal n. also causes pain in joint.
