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Trismus may be defined as inability to open the mouth due to muscle spasm, but the term is usually used for limited movement of the jaw from any cause and usually refers to temporary limitation of movement. Causes of temporary limitation of mandibular movement: 1. Intracapsular causes: Infective arthritis Juvenile arthritis Traumatic arthritis and disc damage Intracapsular condylar fracture 2. Pericapsular causes: Irradiation and other causes of fibrosis Dislocation Condylar neck fracture Infection and inflammation in adjacent tissue 3. Muscular causes: Pain dysfunction syndrome Myalgia caused by bruxism Haematoma from inferior dental nerve block Tetanus 4. Other causes: Oral sub mucous fibrosis Systemic sclerosis (scleroderma) Zygomatic and maxillary fractures Some drugs: phenothyasin, metoclopramide Craniofacial anomalies involving the joint Causes of Trismus: 1. Infection and inflammation in or near the joint: Acute pericoronitis Mumps (Acute myxovirus disease involving parotid gland) Suppurative parotitis Suppurative arthritis Osteomyelitis (inflammation of bone) Cellulites (inflammation of loose connective tissue) Ludwig’s angina Submesseteric abscess Infra-temporal abscess Mandibular block infection Infection in the pterygoid, lateral pharyngeal or submandibular spaces 2. Injuries: Unilateral condylar fracture Bilateral condylar fracture 3. Tetanus and Tetany 4. temporomandibular pain dysfunction syndrome 5. Histerical Trismus 6. Some drugs: phenothyasin, metoclopramide
Management: In all these conditions the essential measure is to relieve the underlying causes. Medicinal: Muscle relaxant Mechanical exercise: o Wooden spatulae o Acrylic screw Use of brisement force
Inability to open the mouth beyond 5mm of interincisal opening due to fusion of the head of the condyle of the mandible with the articulating surface of the glenoid fossa and termed as ankylosis of the Temporomandibular joint. It may be partial or complete or either fibrous or bony. Classification: 1. 2. 3. 4. 5. Partial or complete ankylosis Fibrous or bony ankylosis False ankylosis or true ankylosis Extra-articular or intra articular ankylosis Unilateral or bilateral ankylosis
Causes of Ankylosis: 1. Causes of mechanical interfere with opening (pseudo-ankylosis): Trauma: due to fracture of Zygomatic bone or arch Hyperplasia: developmental over growth of the coronoid process Neoplasia: Osteoma Osteochondroma Osteosarcoma Miscellaneous: congenital anomalies 2. Causes of extra caplsular ankylosis (false-ankylosis): Trauma: wounds or burns which causes periarticular fibrosis Infection: chronic periarticular suppuration Neoplasia: Chondroma Chondrosarcoma Fibrosarcoma of the capsule Particular fibrosis due to: Irradiation Oral submucous fibrosis Progressive systemic sclerosis 3. Causes of intra caplsular ankylosis (true-ankylosis): Trauma: Intra-capsular comminuted fracture of condyle Penetrating wounds Forcep delivery at birth Infection: Otitis media Osteomyelitis of jaw Pyogenic arthritis
Systemic juvenile arthritis: Psoriatic arthropathy Osteo arthritis Rheumatoid arthritis Neoplasia: Osteoma Chondroma Osteochondroma Miscellaneous: Synovial chondromatosis Clinical features: It occurs in any age but commonly occurs below 10 years. Both sexes are equally affected. Inability to open the jaw. Difficulty in mastication the food. Compromised oral hygiene and speech. Disturbance in respiration leading to breathing distress. Patient has multiple carious teeth in the mouth and seeks consultation for tooth-ache. A scar on the chin can be seen with history of trauma. In the unilateral ankylosis, some degree of movement is possible because of the normal joint on the opposite side. In this case, face is asymmetrical with fullness on the affected side of the mandible and flattening on the unaffected side. In bilateral ankylosis, it develops a typical ‘bird face’ appearance with a retruded chin. In fibrous ankylosis, some degree is also possible. In bony ankylosis, interincisal opening is invariably less than 5mm. Radiological examination: X-rays for TMJ both in open and closed mouth position should be taken. In fibrous ankylosis, the joint space is visible but no movement of the condyle is seen. In bony ankylosis, a bony mass is seen in the area of the joint with obliteration of the joint space along with restricted movement of the condyle. Cephalometric radiograph is helpful in assessment of the mandibular and maxillary skeletal defects. Management: 1. Condylectomy 2. Gap arthroplasty 3. Inter positional arthroplasty: Autogenous: o Temporal muscle o Temporal fascia o Dermis o Cartilaginous graftsCostochondral Sternoclavicular Auricular cartilage Alloplastic materials: o Stainless steel o Silastic o Titanium o Tantalum foil/plate
o Teflon (polytetrafluoethlene)
Myofacial pain dysfunction syndrome
Causes: Causes are usually unknown, but some factors are identified: o Oral habits: Para functional activity such as clenching or grinding of the teeth, finger nail, pencil or cheek chewing o Stress, psychological disturbance or psychological factor or psychiatric illness o Occlusal disturbance or disharmony o Decreased vertical height o Trauma or physical injury o Bruxism o True joint diseases Clinical features: 1. It is predominantly a young patient’s condition (20-40yrs) and affects women more commonly than man. Female: male = 4: 1 2. Pain mainly muscle associated pain 3. Pain is dull and worse by mastication 4. Pain felt in front of the ear 5. Limited mouth opening 6. Translatory movement of joint may be normal 7. Joint sound- crepitus or clicking 8. Re-current headache 9. Gar symptoms Treatment: Conservative treatment: 1. First line: Keeping the muscles warm, minimizing chewing, analgesics (NSAIDs) as well as asking the patient to watch for and control daytime Para functional activity. 2. Second line: a) Soft vinyl mouth guard (for night use only, for about 6 weeks). b) The occlusally balanced or stabilization appliance is a rigid acrylic device made to fit closely into the occlusal surfaces of upper and lower tooth. c) Physiotherapy of various forms has been shown to be effective in reducing pain and increasing mobility. d) Antidepressant medications such as amitryptiline, dothiene, fluxetine or paroxetine have been used with considerable success for some patients. e) It is certainly worth while treating any obvious local cause such as pericoronal infection or a high restoration. f) Help should be sought from a psychologist or psychiatrist. Surgical treatment: Arthrocentesis Menisectomy Disc repositioning operation Condylotomy Condylectomy
Dislocation of TMJ
Dislocation of a joint is a displacement of one component of the joint beyond its normal limits, without spontaneous return to its normal position. The condyle moves to articular eminence that marks the anterior limit of the condylar excursion. Once the condyle slips over the articular eminence to come and lie anterior to the eminence in the infratemporal space, it is known to be dislocated. The capsule of the joint along with temporomandibular ligament is either sufficiently relaxed or torn to let this all happen. If both joint are dislocated and the patient is dentate the mouth remains wide open, although sometimes the patient may be able to close toward a protruded position. If only one joint is dislocated then there is a marked deviation to the opposite and the teeth may be brought closer together but still nowhere near back into occlusion. For a few hours after the event there remains a depression just in front of the ear where the condyle would normally be found, but in times that fills with oedema. Classification: 1. Acute 2. Chronic 3. Subluxation Causes: 1. Over-opening of the mouth to its extreme positions such as during a yawn, hefty laugh or mastication of large object (biting a full apple). 2. When the jaws are forcibly opened during general anaesthesia, during bronchoscopy or while using a mouth gag injudiciously. 3. Due to blow on the chin when the mouth is wide open. Treatment: A) Acute dislocation can usually be reduced as an outdoor procedure. Reduction of dislocation of the TMJ: Have the patient supine Stand behind the head Place the thumbs on the posterior teeth and the fingers under the chin Press increasingly firmly on the posterior teeth while pulling gently up anteriorly If there is great resistance concentrate on one side at time When reduced hold the mouth shut for 30 sec or so Advice restricted mouth opening for at least 24 hours At times muscle spasm is so strong that it does not allow the manipulation of the condyle back to its original position, it is advisable to sedate the patient by administration of the muscle relaxant or local anaesthetic solution or even general anaesthesia can be administered. B) In majority of the chronic cases, dislocation of long standing usually requires an open reduction. The patient is taken to the operation theatre and under general anaesthesia jaw is manipulated for closed reduction. If it fails, joint is opened through a conventional preauricular approach. The dislocated condyle is exposed and manipulated under direct vision. The manipulation can be reinforced by exposing the angle of the mandible through a submandibular incision. A hole is drilled there to facilitate the additional downward pull with the help of a wire passed through this hole.
If the above procedure fails, an eminectomy may be performed. This will allow the comfortable repositioning of the condyle into the fossa since the obstruction stands removed.
It is also known asChronic recurrent dislocation Habitual dislocation The term should be reserved for repeated episodes of dislocation, where there is abnormal anterior excursion of the condyle beyond the articular eminence, but the patient is able to manipulate it back into normal position. So there the condylar head moves unassisted, forward and backward over the articular eminence. This recurrent incomplete, self-reducing habitual dislocation is termed as hyper mobility or chronic subluxation of the TMJ. Causes: Ligaments and capsular flaccidity Yawning, vomiting, laughing Also seen in severe epilepsy and Ehlers-Danlos syndrome Management: Intermaxillary fixation or limiting the oral opening by giving elastics for the period of 3-4 weeks. Patient kept on liquid diet. Use of sclerosing solution, inject into the joint space. Ex: Sodium psylliate (not available) Sodium morrhuate (no good result) Sodium tetradecyl sulfate (allergic or not recommended) Surgical procedures: 1. Capsule tightening procedure 2. Creating of a mechanical obstacle 3. Direct restraint of the condyle 4. Creation of a new muscle balance 5. Removal of mechanical obstacleMenisectomy High condylectomy Eminectomy
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