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Temporo Mandibular Joint

Temporo Mandibular Joint

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Temporo Mandibular Joint
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GOOD MORNING TO ALL

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Temporo Mandibular joint

By, Dr.Abinash Mohapatra
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  

 

 

Introduction Embryology & Evolution General features - Anatomy - Physiology - Biomechanics Examination In Children Disorders - Congenital - Acquired - Traumatic - Inflammatory Conclusion References

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Embryology –
Cranial most part – enlarges
Two big bulging in the ventral

aspect of the embryo.
Depression - Stomatodeum

Neural groove – 21st day Closure of neural tube – 23rd day

Elongation b/w the Stomatodeum & Pericardium – Mesodermal thickenings –
Pharyngeal / Branchial Arches

1st arch – Mandibular arch 2nd arch – Hyoid arch 3rd arch 4th arch 6th arch

No Names

5th arch – Disappears soon after formation.

1st – Meckels cartilage , incus &
malleus , also ant. lig. of malleus & Sphenomandibular lig

2nd - Stapes , Styloid process , Stylohyoid lig , Smaller cornu of hyoid , Superior part of body of hyoid.
3rd – Greater cornu of hyoid bone , lower part of the body of hyoid bone. 4th & 6th – Cartilages of larynx.

4th to 28 weeks

Development of TMJ → Acc to Baume, temporomandibular articulation originate from two different blastema. The Condylar blastema & the Temporal blastema.

Condylar blastema –(primodium of the mandible) - condylar cartilage - the aponeurosis of the external pterygoid muscle - the disc - the capsular elements of the lower joint.

Temporal Blastema – - Articular structures of the upper level

Condylar blastema forms at the distal end of the primordium of the mandible.
The mandible begins to ossify – 7th week of fetal life / 19mm stage of fetal development. 22mm stage / 8th week – bone laid down in a platelike form lateral to Meckels cartilage.

Horizontal section of developing mandible 8th week IU
Meckels cartilage extends from the Cartilaginous otic capsule to the midline symphysis Bone of the mandible is forming in the membrane Tongue Meckels cartilage

Phylogenetically , the developing middle ear in primates & especially the humans was the initial jaw joint of the vertebrates In the middle ear region that the malleus & probably the incus develop as posterior extentions of Meckels cartilage. The intermediate portion of Meckels cartilage disappears, but its sheath remains to persist in the form of anterior malleolar ligament & the sphenomandibular lig.

A -relationship b/w mandible & middle ear. B -reference to Meckels cartilage.

A -Anterior malleolar lig.

B -Malleus C - Incus

24mm stage embryo, the pterygoid & masseter muscles have differentiated. At the superior border of the external pterygoid muscle & just below to the masseter muscle, a layer / bulk of mesenchyme tissue which is the anlage of articular disc. 28mm stage the middle ear ossicles are fully formed in true cartilage & malleus is continuous with the Meckels cartilage. -Articular disc & external pterygoid tendons are attached to the malleus.

11th week – condylar cartilage becomes evident, located at the upper end of the posterior border of developing mandible. 30mm stage embryo – articular surface faces directly lateral, it is parallel to the articular disc as well as to the articular surface of the zygomatic process of the temporal bone.

50mm stage – condylar cartilage shapes the articulating surface of the condyle in a hemisphere.

-

Articular disc has flattened & the plane of the articular surfaces has undertaken a shift of 450
55mm stage – condylar head produces an osseous head which matures into condylar cartilage by 65mm stage – Baume. 85mm stage – ossification of the cartilage begins, growth center of the mandible. - joint cavity formation is evident as the loose connective tissue on either side of the future articular disc becomes less dense.

Inferior portion of the joint cavity takes the shape of a distinct cleft. 13th week – the lower joint cavity is well formed around the superior surface of the condyle, so as the upper part. 15th week – vascular mesenchyme of the condylar cartilage can be seen breaking down. - both joint cavities are formed.

At 155mm stage – differentiation continues anteriorly to arrive at a point of full articulation. 190mm stage – all the elements of the joint are fully formed. Baume, full differentiation of all articular elements by 4th fetal month.

14 weeks of Human Fetus
Parietal bone Occipital Frontal bone Squamous Part Secondary condylar Cartilage Ramus

vv

Secondary coronoid cartilage
Maxilla Body of mandible

8th – 10th weeks IU – proliferation & histodifferentiation takes place & condyle assumes its mature morphogenic pattern. Also 1st evidence of temporal bone 12th – 14th week IU – formation of articular disc 22nd week IU – both articular eminence & the glenoid fossa are well formed

 

Meckels cartilage plays no role in actual dev of TMJ, acts as a frame work / scaffold for the dev mandible.
Ramus formed of membranous bone & endo chondral bone formation at the head of the condyle. Early attachment of muscles of mastication – 8th week. Attachment of external pterygoid – 13th week. Masseter muscle attachment – 14th week.

 

Joint Innervation – Kitamura; - branches of Auriculotemporal nerve, masseter nerve, & the posterior deep temporal nerve
Branches of Mandibular portion of Trigeminal N.

4th fetal month – nerve fibers may be observed in the articular capsule

5th month – appear to reach the disc.
6th month – widest distribution over the condyle & within the disc. Localization & distribution of nerve fibers at joint margins.

Nerve fibers in capsule innervate the synovial membrane of the joint as well.

Du Brul; - the key relationship b/w jaw & ear dysfunction lies in the embryological development of the neural patterns of the TMJ. - demonstrated that the nerve to the internal pterygoid muscle also sends a branch to tensor tympani muscle (moves the malleus) He states unequivocally that, “ Herein lies the key to the relationship b/w jaw & ear dysfunctions sometimes plaguing modern man along with the deteriorating of other parts of jaw & dental apparatus”

A – Mandible at birth

B – At 6 years
C – In an Adult

Lateral View

Occulsal View A- At birth B- At 6 yrs C- Adult

Evolution

of

Jaw Joint

An amphibian jaw- articulation b/w
the terminal portion of Meckels cartilage & the palatoquadrate bar. Teeth are confined to the dentary bone

A reptile jaw- dentary is of increased
size

Fossil mammal like reptileenlarged dentary & has coronoid process

Mammals- Articulation of dentary
with the temporal bone & constitutes part of inner ear.

Classification of joint :


Fibrous joint Cartilaginous joint Synovial joint

Temporomandibular articulation is a synovial joint - provides both hinging movement ( ginglymoid joint ) in one plane & gliding movements ( arthroidial joint ) – ginglymoarthroidial joint .

Temporomandibular joint proper -

The three major skeletal components that make up the masticatory system :

Maxilla
Mandible Temporal bone

Temporal bone -

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A- mandibular fossa B- external acoustic meatus C- articular eminence D- zygomatic process E- tympanic plate F- petrosquamous fissure

A- body B- ramus C- incisive fossa D- mental foramena E- angle F- external oblique line G- coronoid process H- condyle I- mental tubercule

A- genial spine (tubercles) B- internal oblique ridge C- attach. area for medial pterygoid D- temporal crest E- retromolar triangle F- mandibular foramena G- lingula H- mylohyoid groove I- digastric fossa

Condyle LP- lateral pole MP- medial pole pterygoid fovea

1450

line drawn through the centers of the poles of the condyles, usually extends medially & posteriorly towards the anterior border of the foramen magnum.

Total medio-lateral length – 15 – 20 mm The anteroposterior width – 8 – 10 mm The articulating surface of the condyle extends both anteriorly & posteriorly to the most superior aspect of the condyle. Posterior articulating surface is greater than anterior surface & is quite convex anteroposteriorly & only slightly convex mediolaterally.

Condyle of a child –
-

Histologically the appearance varies with age, due to presence of secondary cartilage. This cartilage appears about 10th month IU & remains as a zone of proliferating cartilage until about the later half of the second decade of life. The condyle of the young child is not lined by a distinct layer of compact bone as is that of the adult.

-

-

A- fibrous articular layer B- cell rich proliferative layer C- hypertrophic condrocytes of the secondary cartilage D- woven bone being deposited around E- a template of calcified cartilage F- marrow space

-multinucleated osteoclast - osteoblast layer depositing bone on calcified cartilage.

A – head of adult condyle B – lower part of intraarticular disc C – fibrous articular layer (collagen are crimmped)

A – collagen fibers at the centre B – regularly aligned at periphery C – larger marrow spaces & lack of a layer of compact bone D – articular surface of mandibular fossa

Histology of articular surface-

A – condyle head B – fibrous articular surface zone C – cellular rich zone D – fibrocartilagenous zone E – zone of calcified cartilage F – lower joint space G – intra articular space

Articular disc –
-

Composed of dense fibrous connective tissue Extreme periphery of the disc , is innervated Sagittal plane –

AB- anterior border PB- posterior border IZ- intermediate zone

Anterior view – the disc is slight thicker medially than laterally.

LP- lateral pole MP- medial pole

-Sagittal section of the intra- - Adult inta articular disc articular disc of a neonate - shows sparse distribution -presence of numerous of cells fibroblasts. - rounded cartilage -like cells

ACL- anterior capsular lig. IC- inferior joint cavity IRL- inferior retrodiscal lamina SC- superior joint cavity
SRL- superior retrodiscal lamina

AS- articular surface ILP- inferior lateral pterygoid muscles RT- retrodiscal tissues SLP- superior lateral pterygoid muscles

ELASTIC

COLLAGENOUS

The articular disc is attached to the capsular lig.,not only anteriorly & posteriorly, but also medially & laterally; this attachment divides the joint into ;

a) the upper cavity [superior cavity] b) the lower cavity [inferior cavity]
Upper is bordered by, the mandibular fossa & the superior surface of the disc. Lower is by, the mandibular condyle & the inferior surface of the disc.

Specialized endothelial cells forms a synovial lining surrounding the internal surface of the cavities. This lining along with a specialized synovial fringe located at the anterior border of the retrodiscal tissues, produce synovial fluid.

Synovial Fluid –
i) metabolic requirements to the non-vascular articular surfaces of the joint. ii) lubrication during function, reducing friction.

Lubrication – i) Boundary lubrication ii) Weeping lubrication

Boundary lub – -when the joint moves, the synovial fluid is forced from one area of the cavity to another. -prevents friction & is the primary mechanism of joint lub.
Weeping lub – -the ability of the articular surfaces to absorb a small amount of fluid. -forces during function drive a small amount of fluid in & out of the articular tissues, helps in metabolic exchange.

Compressive forces of articular tissues.

release fluid & prevents sticking

Weeping eliminates friction in compressed but not moving joint.

But prolonged compressive forces will exhausts this supply leading to deleterious effects.

Crimping of collagen fibers in the intra articular disc is indicative of tensional loads. About 2/3rd s of the glycosaminoglycan is chondroitin sulphate & 1/3rd is dermatan sulphate, traces of hyaluronan & heparin sulphate.

Innervation of TMJ –
- The trigeminal nerve , that provides both motor & sensory innervation to the muscles that control it. - Afferent innervation – branches of the mandibular nerve. - Also by auriculo-temporal nerve as it leaves the mandibular nerve behind the joint & ascends laterally & superior to wrap around the posterior region of the joint. - Additional nerves – temporal & masseteric .

Vascularization –
- predominantly ;
i) from posterior- superficial temporal artery ii) from anterior- middle meningeal artery iii) from inferior- internal maxillary artery iv) others ; - the deep auricular - anterior tympanic - ascending pharyngeal arteries - condyle, receives through its marrow spaces by “feeder vessels” from inferior alveolar artery.

ligaments

Made up of collagenous connective tissues having particular lengths & they do not stretch. Act as passive restraining devices to limit & restrict border movements. The three functional ligs ;

i) the collateral lig ii) the capsular lig iii) the temporomandibular lig

AD- Articular disc CL- Capsular ligament IC- Inferior joint cavity SC- Superior joint cavity LDL- Lateral discal lig MDL- Medial discal lig

Collateral (discal ligaments) : - Attaches the medial & lateral borders of the articular disc to the poles of the condyles. - Divides the joint mediolaterally into the superior & inferior cavities. - True ligs , do not stretch & restricts movement of the disc away from condyle. - Responsible for hinging movement of the TMJ.

- Have both vascular as well as innervation , providing information regarding joint position & movement.
- Strain on these ligs produces pain.

Capsular ligament
- surrounds & encompasses the entire TMJ. - superiorly to the temporal bone along the borders of the articular surfaces of the mandibular fossa & articular eminence. - inferiorly – neck of the condyle - resist any medial, lateral / inferior forces that tend to separate / dislocate the articular surfaces. - helps to retain synovial fluid & provides proprioceptive feedback.

Temporomandibular (Lateral) ligament
IHPInner horizontal portion

OOPOuter oblique portion

Oblique portion – resists excessive dropping of the condyle - normal opening of the mouth. - wider mouth opening- the condyle moves downwards & forward across the articular eminence. - unique limited rotational opening is found only in humans.

- in erect postural position & with a vertically placed
vertical column, continued rotational opening movement would cause the mandible to impinge on the vital submandibular & retro-mandibular structures of the neck. Inner horizontal portion ; - limits the posterior movement of the condyle & disc. - protects the retrodiscal tissues from trauma. - also protects the lateral pterygoid muscle from overlengthening / extension - trauma to the mandible – neck of the condyle will fracture before the retrodiscal tissues are severed / before the condyle enters the middle cranial fossa.

Accessory ligs ; i) the sphenomandibular lig ii) the stylomandibular lig

iii) the pterygomandibular raphe iv) the retinacular lig

Muscles of Mastication a) the masseter lie on superficial face b) the temporalis c) the medial pterygoid & lie deep within the d) the lateral pterygoid infratemporal fossa

- all the muscles dev from the mesenchyme of the 1st brachial arch.

MASSETER

DP- deep portion & SP – superficial portion function- elevation of the mandible & grinding hard food, some retrusive capability (post. fibre orientation

TEMPORALIS

AP- anterior portion , MP- middle portion & PP- posterior portion. Largest muscle of mast. function- elevation (anterior portion) retraction (posterior portion)

MEDIAL PTERYGOID MUSCLE MEDIAL PTERYGOID MUSCLES-

Originates-pterygoid fossa,extends downwards,backwards, outward to insert along the medial surface of the angle. With masseter it forms the muscular sling function- elevation,also active in protruding the mandible. unilateral contraction- mediotrusive movement

LATERAL PTERYGOID MUSCLE

Inferior lat pterygoid- contraction of both rt. & lt., the condyle is pulled down the articular eminences- mandible is protruded. Unilateral- mediotrusive movement. Superior – active during power stroke & when the teeth are held together / clenced.

BIOMECHANICS OF TMJ –
Can be divided into two system: 1) One joint system;

Tissues surrounding the inferior synovial cavity (condyle & the articular disc) Only physiologic movement is rotation of the disc on the articular surface of the condyle – condyle-disc complex. Responsible for rotational movement in the TMJ.

2) condyle-disc complex functioning against the surface of mandibular fossa;

Free sliding movement possible, in the superior cavity. This movement occurs when the mandible is moved forward – translation.

Articular disc is not a meniscus.  Meniscus – is a wedge shaped crescent of fibrocartilage attached on one side to the articular capsule & unattached on the other side,extending freely into the joint spaces. - functions passively to facilitate movement.

The articular surfaces of the joint is maintained by constant activity of the muscles that pull across the joint, primarily the elevators. (even in resting stage in a mild tonus) Increase in intraarticuar pressure holds the joint. Width of the disc varies with the intraarticular pressure. - low (closed rest position) – widens. - high (clenced) – space narrows.

Posterior border of the articular disc – retrodiscal tissues. Opening of the mandible – the superior retrodiscal tissue gets stretched, creating increased force to retract the disc. Mandible moves into full forward position & during its return – retraction force of the sup. retrodiscal tissue holds the disc rotated as far posteriorly on the condyle as the width of the articular disc permits.

The sup retrodiscal tissue – only structure capable to retract the disc posteriorly on the condyle (wide opening movements)

Anterior border of the disc – attachment of the superior lateral pterygoid muscle. (also attached to the neck of the condyle)

Helps in protraction of the disc, dual attachment doesn’t allow the muscle to pull the disc through the discal space The inferior lat pterygoid when protract the condyle forward, the superior fibers is inactive – disc is not moved forward with the mandible.
The superior lat pterygoid is activated only in conjunction with elevator muscles. (closure / power strokes)

During translation, the combination of disc morphology & interarticular pressure maintains the condyle on the intermediate zone – disc is forced to translate forward with the condyle. When the morphology of the disc has been altered, the ligamentous attachment of the disc affects joint function.

Things to remember :  ligaments; -do not actively participate in normal functioning of the TMJ -act as guide wires,restricting & permitting some movements -restrict joint movements both by mechanical & through neuromuscular reflex activity.

Ligaments do not stretch (ability to return to its original length) - traction force- elongates, if elongates then often the function is compromised.

Articular surfaces of the TMJs must remain in constant contact (the elevators ; temporal, masseter, & medial pterygoid)

SKELETAL MUSCLE

Occupies one half the body wt., > one half the body water, & it has an extracellular fluid > the blood plasma volume. Motor unit consists ; - the motor neuron leaving the ventral horn of the spinal cord - its axonal extentions - the myoneural junction (synaptic gutter) & - terminally the muscle fibers. Huxley (1956) ; - main protein unit are actin & myosin, had the ability to interact & produce movements.

-skeletal muscles are many
bundles of fibers -each bundle-no.of parallel fibers (sarcoplasm) -myofibrils are embedded in the sarcoplasm. -each fiber is surrounded by a delicate elastic sheath (sarcolemma)

Masticatory muscles contain all three fiber types.
Muscle contraction;

- stimulation → motor neuron → contraction of motor unit - cessation of stimulation → relaxed unit. - Isotonic → contractile activity may shorten the muscle under constant loading, thus inducing skeletal movement

- Isometric → contractile activity may increase tension within
the muscle while maintaining a constant muscle length, producing a holding action.

Muscle tonus ; resistance to elongate / stretch.

- hypertonicity – relative increase in passive resistance to stretching muscles - hypotonicity – decrease resistance to stretch. - serves : a) helps to maintain contact of articulating parts in the joint (at rest / under –ve effect of gravity) b) keeps the muscles in an optimum readiness for contraction.

REFLEX ACTIVITY
Myostatic / stretch reflex : Muscle spindles are the receptors.  They are sensitive to both structural length & rate of change of elongation.  Reflex operates → stretch of the spindles → muscle tonus → continuous surface contact in synovial joint (-ve effect of gravity tends to separate them)  Mandibular elevator muscles have the most muscle spindles.  Maintains the passive interarticular pressure in the TMJ & is an imp. determinant of mandibular rest position.

Nociceptor / flexon reflex :

Sudden ,unexpected painful stimulation of a part occurs, muscles automatically reacts to the cause withdrawal from the source of noxious input.

Jaw -opening reflex → bite on hard object. - active contraction of depressor & protractor muscles takes place with simultaneous relaxation of antagonist elevator muscles. - this reflex is initiated by pain.

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Mandibular rest position :

-Physiologic rest position → muscle tonus of the elevator muscles → myostatic reflex (affected by the wt. of the mandible) -Rest position → 1.3 – 3.0 mm of interocclusal clearance (freeway space) - Changes with head posture & muscle tonus. -Varies with head position, total body posture, functional activities, fatigue, time of day, age & emotional tension.

VERTICAL DIMENSION OF OCCLUSION
Increase in VDO → increased activity in the elevator muscles, with pain & resulting in dysfunction. Akagawa et al; - within interocclusal clearance displayed → transient acute inflammation in the deep & superficial masseter muscle. - more than 1mm → early acute inflammation to muscle fiber regeneration in the deep masseter, with a lesser degree in superficial masseter & ant. temporal muscle. Carlson et al; - VDO can be altered by using bite planes, without affecting muscle tonus of the mandibular muscles.

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Examination of TMJ in pediatric patient

Posture of the clinician & patient

  

Palpation – in closed, at rest & various open position Deviation should be noted Crepitus / abnormal sound Palpation of the neck & sub mandibular area Speech evaluation

Standard for TMJ evaluation in the pediatric patient pediatric dentistry 1989- 11(4);330 History ; 1) Does your child report any pain during chewing / while opening the mouth wide? 2) Child report any discomfort in the jaws upon awakening 3) Child complains of headache 4) Any history of trauma to the jaws or neck region? 5) History of allergies? 6) Jaw click / lock upon opening?

+ve history – pain manifestation, stress, balanced diet, sleeping posture

 

Clinical examination : gentle & cautious palpation of muscles of mastication. - for trigger points - rated, 0 – no pain ; 1- tenderness ; 2 – definite pain ; 3 – evasive action.

Range of movement : -maximum opening & lateral excursions -widest opening – 40mm -anterior bite depth – 34mm -overbite – 6mm Click : -early, late, or both on opening.

Radiographic examination & advances : - transcranial radiographs / tomograms - MRI & arthrograms

Temporomandibular disorders in children
Jeffrey P.Okeson
Pediatric Dentistry: Dec;1989:11(4);325-329

1)

Are TM disorders a problem in children ?

2)

How TM disorders treated in children ?
Can early treatment prevent TM disorders ?

3)

Are TM disorders a problem in children? -epidemiologic studies – 10-18 yrs. -studies place the findings into two categories via; a) symptoms b) signs -common in young population – few complain

How are TM disorders treated in children? -Ingerslev – conservative & reversible -occlusal appliance - < 2 months

Two major categories : a) masticatory b) disc- interference / internal dearangements

Can early treatment prevent TM disorders?
-etiology is of paramount importance -occlusal condition

-no scientific evidence

Prevelence of TMJ disorders in children Eup J.orthod 14;152-161:1992

A longitudinal study,for the signs & symptoms of CMD in 12-15 yr old individuals. “during this period there is an increased prevalence of S/S of CMD. In particular true for headache & joint sounds.

Heritability of TMJ disorder signs & symptoms
 

J dent.res 79(8):1573-1578,2000. Genetic variance & environmental variances This study results suggest that neither shared genes nor the family environment accounts for much of variance in TMJ related s/s & oral habits. TMJ-pain was reported by 8.7% of the twins – Lipton et al 1993. Joint noises & locking in these twins were also about as prevalent as in non-twin population.
Pain reporting in particular is influenced by mood, stress, learned behaviors, physiological pain threshold.- Mogil et al 1996.

They concluded that

i) Genetic factor do not influence joint disorders manifesting pain. or ii) Pain perception factors are non-genetic, supported by twin study of pain threshold – MacGregor et al ;1997.

So till date no study has substantial evidence of any genetic relation of joint pain.

TMJ disorders – (intra capsular disorders) Physical examination- inspection for the pattern & the presence of noise / deviation on opening Normal vertical opening – width of three fingers Diff b/w maximal pain –free opening & maximal opening with pain Child is asked to point the area of pain Muscle of mastication palpated Magnitude of opening ;

Maximal incisal opening of less than 20-25mm- muscle spasm Periauricular pain beginning at 25-30mm- TMJ capsulitis

Lateral movements ; > 5mm –well functioning TMJ normal lateral but painful vertical opening –muscle spasm 1 min clench test : Tongue blade placed unilaterally on the posterior teeth –if hyperactivity muscle – ipsilateral pain Capsulitis –pain on the contralateral side Placed bilaterally – if pain relieved – splint therapy.

-

-

TMJ noises : -click – 2-3 trials indicates disc displacement -during vertical & lateral motion.

TMJ tenderness ;

 Patient open slightly bringing the condyle & disc from under the zygomatic arch.  Retro discal area palpated – wide open mouth  The surface posterior to the condyle is pressed  Little fingers can be placed in the external auditory canal  Lateral / posterior sensitivity – either capsulitis / synovitis or both.

Joint inflammation ; -synovial, capsular / retrodiscal tissues – capsulitis or synovitis -due to infection, trauma, systemic diseases, articular surface degeneration / disk displacement -preauricular pain -episodic swelling with occlusal changes can occur.

TMJ dislocation (open lock) -subluxation -painful -jaw manipulation


1.
2. 3.

Treatment of joint disorders –
Patient’s education Pain free diet Therapeutic exercises to rehabilitate the joint Anti-inflammatory drugs &muscle relaxants

4.


1. 2.

Physical therapy –
Heat / ice massage Gentle range of motion exercises with in the pain tolerance.( 6 times a day for 30-60 secs ) Joint shouldn’t hurt more than 10mins after exercise Night time splint – reduces forces on the joint.

3. 4.

5.

Night guard, controls parafunctional habit, temporary stabilizes an uneven occlusion – allows the joint to rest. Should have a flat plane – opening the bite several mm.

6.

7.

Soft night guard is given for children with developing occlusion / mixed dentition.

8)

Painful click – mandibular orthopedic repositioning appliance

Extra capsular disorders -

Acute disorders :

I)

Myositis- due to infection / injury Protective muscle spinting – constriction of muscles to avoid pain, pain in function Myospasm (acute trismus) – involuntary,sudden,tonic contraction of muscles

II)

III)

Chronic disorders :

Myofacial pain –

-most common in children -jaw function aggravates headache. -localized tender / trigger points (active / passive) -tender spots may produce characteristic pattern of referred pain.

-can be caused by postural problems, parafunctional habits, psychological disorders, stress & trauma. -pain is reduced / eliminated with anesthetic injection into active trigger points, or a spray & stretch procedure with fluormethane spray.
-long term - elimination of the contributing factor.

-analgesics, muscle relaxants, behaviour modification & home rehabilitation & physical therapy.

Myofascial Pain – Dysfunction Syndrome (MPDS) or Temporomandibular Joint Pain Dysfunction Syndrome or Masticatory Myalgesia Syndrome

Schwartz in 1955.

Etiology : - masticatory muscle spasm, due to muscular overextension / muscular over contraction / muscle fatigue. - habits like clenching / grinding - Laskin et al – the “psycho- physiologic theory” - occlusal disharmony – altered chewing pattern.

c/f ; - 80% - 90% - females (< 40yrs) Four cardinal signs : Pain Muscle tenderness Clicking / popping noise in the joint Limitation of jaw motion (unilaterally / bilaterally) Two typical –ve disease charecteristics Absence of clinical, radiographic / biochemical evidence of organic changes in the joint & Lack of tenderness in the joint.

1)
2) 3)

4)

1)

2)

Treatment :

-conservative -relief of emotional factors, faulty restorations & appliances -myotherapeutic exercises & physiotherapy -drugs ; tranquilizers & muscle relaxants.

Correlation b/w occlusal characteristics & TMD JCPD 24;229-236 ;2000 Study showed a significant correlation b/w posterior cross bite & TMD. Egermark – Erikson –association b/w cross bite & muscle tenderness. 1985 – Brandt compared cross bite to clicking, significant. Anterior openbite & edge to edge relationship with TMD

- Egermark – Erikson –frontal openbite & crossbite may predispose to mandibular dysfunction. - Seligman & Pullinger –ant openbite was the variable with the greatest influence on the presence of TMJ tenderness.

They concluded that :

Significant correlation was found b/w TMD & a) posterior crossbite b) openbite & edge to edge occlusion c) class III canine relationship.

Congenital abnormalities of TMJ:
Hemifacial microsomia (HFM) ;

-variable, progressive, & asymmetric craniofacial deformity -involves the skeletal, soft tissue & neuromuscular components of the 1st &2nd pharyngeal arch -Poswillo – hemorrhage from the developing stapedial artery produces a hematoma in the area of the 1st & 2nd arches.  Facial growth : - asymmetric mandibular growth (unilateral / bilateral) - growth is impaired with short, retrusive & narrow mandible

Classification

 Acc to skeletal defects

Type I – consists of a mini-mandible & TMJ -all str. are present, normal in shape & location but small
Type II – small mandible with a hypoplastic TMJ i) type II A degree & location of hypoplasia ii) type II B

Type III – complete absence of ramus & TMJ.

HFM

 Acc to jaw motion & dev of muscles of mastication  Type I – - both jaw motion, articular disc & muscles present.

Type IIA & B – - hypoplastic, muscles of mastication & articular disc - translatory & lateral movements are restricted.
Type III –

- lateral pterygoid & articular disc are absent - moderately to severely hypoplastic temporalis, masseter & medial pterygoid. - doesn’t translate to affected side & move medially towards the normal side

End stage of skeletal defect :

1.

Short, medially, placed ramus & TMJ. Mandible – flat in contour & chin point deviated towards the effected side. Short midface – resulting in a canted occlusal plane ( ↓ distance b/w the infraorbital rim, piriform aperature, & maxillary alveolus) Flat zygomatic bone, orbit sometimes is inferiorly present

2.

3.

4.

 Acc to soft tissue defects:

Mild ; - minimal subcutaneous & muscle hypoplasia. - absence / slight macrostomia - mild auricular defect (pre-auricular tags)

Severe ; - severe hyploplasia- subcutaneous & muscles - facial clefts - macrostomia - neuromuscular weakness  Moderate

 Acc to ear anomaly ( Meurman)
1.

Grade I ; mild hypoplasia & cupping

2.

Grade II ; absence of external auditory canal & hypoplasia of concha Grade III ; auricle is absent, anteriorly & inferiorly displaced lobule.

3.

Conductive hearing loss – hypoplasia of ear ossicles.

OMENS classification : Vento et al

O – Orbit M – Mandible (& TMJ) E – Ear

N – Nerves
S – Soft tissues

Scoring ; Orbit – 0 -normal 1 -abnormal size 2 -position 3 -both Mandible – 0 -normal 1 -type I 2A -type II A 2B -type II B 3 -type III

Ears – Meurman’s system
Nerves – Facial defect Soft tissues – 0-normal -no involvement 1-mild -upper, lower / all branches 2-moderate 3-severe

Treacher Collins syndrome : mandibular dysostosis

• Autosomal dominant • Due to an insult to the neural crest cells (4-6 weeks of embryogenesis) c/f ; Treacher collin (1900) • anomalies are bilateral & symmetrical • Antimongoloid (downward) cant of the palpebral fissure • Colomba at the junction of outer & middle 3rd of lower eyelids • Absence of eyelashes • Ears are low set & hypoplastic

• Nose is large, the zygomatic bones & arches are hypoplastic or missing • Frontozygomatic suture is inferiorly displaced –orbits are “tear drop” in shape.

• • • •

Bilateral facial microsomia : They have similar skeletal deformities Do not show charecteristic soft tissue defects around the eyelids. Asymmetrical defect No inheritance pattern

Developmental disturbances : Aplasia of the condyle – a) unilateral b) bilateral  c/f – -anatomically related defects ; defective or absent external ear, an underdeveloped ramus or macrostomia. -facial assymetry  Treatment – -osteoplasty (if derangement is severe) -orthodontic appliance -cosmetic correction – correcting facial deformity.

Hypoplasia of condyle

a) congenital b) acquired
Congenital hypoplasia : (idopathic)  Unilateral  Bilateral Acquired hypoplasia :  Forcep delivery  External trauma  X-ray radiation for local treatment of skin lesions  Infections  Endocrine or vitamin derangement

c/f – a) depends on its effect on one / both condyle b) degree of malformation c) age of the patient d) duration of injury & its severity

Unilateral (common) – i) Facial asymmetry ii) Limited lateral excursion iii) Mandibular midline shift during opening & closing due to lack of downward & forward growth of the body of mandible.

Treatment & prognosis :

-poor as there no means to stimulate growth locally

-cartilage or bone transplants -costochondral grafts to mimic condylar head & - metatarsal grafts has shown growth potential

Hyperplasia of the mandibular condyle -unilateral in most cases resembling an osteoma or chondroma c/f – - pt exhibits a unilateral ,slow progressive elongation of the face with deviation of the chin away from affected side. -condyle evident clinically & palpable -striking radiographically appearance in AP& lateral view. -may or maynot be painful -severe malocclusion. Treatment - resection of the condyle - correction of facial asymmetry

Ankylosis (hypomobility) Etiology: Straith & Lewis; a) Abnormal IU life b) Birth injury c) Trauma to the chin d) Malunion of condylar # e) Loss of tissue with scarring f) Congenital syphilis g) Primary inflammation of the joint h) Secondary inflammation to a blood stream disease i) Metastatic malignancies j) Inflammation secondary to radiation therapy

c/f – -any age group -before age of 10 yrs -both sexes affected -difficult in opening mouth. Complete ankylosis; -bony fusion with limited motion -associated with facial deformity

a) Unilateral ankylosis-the chin is displaced laterally & backward on the affected side

b) bilateral ankylosis ; -maxillary incisors manifests over jet due to failure of the mandibular growth. TMJ ankylosis : a) intra-articular b) extra- articular

Intra-articular – joint undergoes progressive destruction of the articular disc with flattening of the mandibular fossa. Extra-articular – splinting of the TMJ by a fibrous / bony mass external to the joint proper (as in infections) Treatment is surgical (osteotomy)


a) b)

c)

Injuries to the articular disc Etiology : Malocclusion Episode of acute trauma to the jaw Inflammatory conditions c/f : Common in female Young adults & persons > 40yrs Characterized by, - pain - snapping / clicking & crepitation in the joint area - transient / prolonged locking of jaw

 a) b) c)

s/s ; -pt.may complain of dull pain in & around the ear or on the side of the jaw, with tinnitus, & dysesthesia of the tongue reported in some cases.

Diagnosis radiographs in both open & closed position. Treatment – -immobilization of jaws- severe pain -malocclusion correction -meniscetomy

Inflammatory disturbances of the TMJ Arthritis / inflammation of the TMJ :  Due to infection  Rheumatoid  Osteoarthritis / degenerative joint disease.

Due to specific infection ;

- resulting from gonococci, streptococci, staphylococci, pneumococci & tubercle bacillus (polyarticular involvment) -gonococci effects the joint – Markowitz & Gerry.

c/f ; -severe pain with tenderness to palpation -motion is severely limited -healing results in ankylosis (osseous or fibrous)
Treatment ; -antibiotics -acute phase –less deforming -chronic phase / advanced stage – menisectomy or condylectomy

Rheumatoid arthritis : Etiology ; -idiopathic -early adult life -female : male -2 : 1

c/f ; -polyarticular & bilateral -episodic exacerbations & remissions -early stages : low fever, loss of wt & fatigability. -joint are swollen, pain & stiffness

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Still’s disease : -may cause a malocclusion of the class II div I type, with protrusion of the maxillary incisors & an anterior openbite.
-radiograph reveal flattening & stunting of the condyles & haziness about the joint indicative of periarticular fibrosis.

Treatment : -administration of ACTH / cortison -limitation of motion – condylectomy .

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Conclusion –

“ The clinician who only looks at occlusion is missing as much as the clinician who never looks at occlusion ” OKESON

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References :

Management of Temporomandibular Disorders & occlusion -JEFFREY P.OKESON Diseases of the temporomandibular apparatus - DOUGLAS H. MORGAN Pediatric oral & maxillofacial surgery - L B.KABAN Oral anatomy, histology & embryology - BERKOVITZ DCNA –vol.27,no.3,july 1983 Bell’s orofacial pain -5th edi www.dentistpro.org to find more

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