BONY ANATOMY

Saggital aspect

coronal aspect

Glenoid fossa & articular eminence

TMJ CORONAL VIEW

ARTICULAR CARTILAGE

TMJ LATERAL VIEW

SOFT TISSUE ANATOMY

TMJ capsule TMJ ligaments Disc(meniscus) Synovial membrane

TMJ LIGAMENTS

CAPSULAR LIGAMENT (LATERAL VIEW)

 TMJ

WITH MUSCLE ATTACHMENT

TEMPORALIS MUSCLE
(WITH ZYGOMATIC ARCH & MASSETER MUSCLE REMOVED)

MASSETER MUSCLE

LATERAL & MEDIAL PTERYGOID

Blood supplyBranches from Superficial temporal & Maxillary Artery Nerve supplyAuriculotemporal & Masseteric Nerve

TMJ PATHOLOGY – PT’S HISTORY

TMJ PATHOLOGY , PATIENT'S HISTORY
 Age

-

Younger-MPDS common Older degenerative disease common Higher class people

 Occupation  H/O pain MPDS - dull & morning time TMJ pain - Sharp & increased during function

 Jaw & joints symptoms

 Oral habit :  Medical history :

Bruxism Chewing pattern Rheumatoid arthritis Extraction Trauma Headache Back pain Ear ache Rheumatoid arthritis Osteoarthritis

 H/O

:

Family history :

CLINICAL EXAMINATION      Facial symmetry Mouth opening TMJ palpation Muscle palpation Dental examination

MYOFASCIAL PAIN DYSFUNCTION SYNDROME or MASTICATORY MYALGIA or COSTEIN’S SYNDROME or TMJ ARTHROSIS

MPDS is a pain disorder, in which unilateral pain is reffered from the trigger points in myofacial structure, to the muscles of the head n neck. pain is constsnt, dull ache I contrast to sharp shooting , intermittent pain of neuralgias(chronic pain). But the pain may range from mild to intolerable.

history
 Occlusion

theory : costen ( 1934 ) he reported association of bite closure (due to loss of posterior teeth) with symptoms like ear pain,sinus pain, decreased hearing, tinnitus, dizzinus, burning n vertigo n occipital headaches(bite raising era)

Psychophysiologic theory: laskin (1969) he states that psychologic stress leads to myospasm (tranquilizers,muscle relaxants)

SYMPTOMS OF MPDS
 CARDINAL

SYMPTOMS: pain or discomfort in head or neck  Limitation of the motion of the jaw  Joint noises-grating , clicking , snapping  Tenderness to palpation of muscle of mastication.  Associated symptoms: Neurologic– tingling , numbness  G I track – nausea , vommiting, diarrhoea  Musculo skeletal – fatigue, tention, shift jt. Pain  Otologic – ear pain, dizziness, vertigo

MANANGMENT:
Initial treatment & recommendation may include 1) spray & stretch. Fluoromethane refrigerant spray 2) Injection of trigger point. . 3 ) a relatively soft diet 4) Medications:- aspirin, piroxicam, ibuprofen, pentazocine, methacarbamol, amitryptiline. 5) Discontinuing of daytime any para functional habits. 6) Diazepam. 2 mg for 2 week. Anxiety reducing & muscle relaxant properties

6) occlusal splint. stabilization & relaxation splints
Adv. Greater freedom in mandibular movement & to increase muscle balance. Disadv. Cause extrusion of posterior teeth results in open bite. 7) Physical therapy. ultra sound(0.7 to 1.0 watts/cm2 for 10 min. every alternate day) moist heat(with towel for 15 to 20min.4 times a day) occlusal adjustment. active stretch exercises. 8) Biofeedback. 9) TMJ arthrocentesis

10. TENS [transcuteneous electric nerve stimulation] M/A. 1) neurological action. 2) Physiologic effect. 3) pharmacological action. Stimulate release of endorphins, which are endogenous morphine like substens. 4) Placebo effect.

DIAGNOSTIC STUDY

Plain radiography:
Trans orbital view or antero-posterior view.  Trans cranial or lateral view.  Trans pharyngeal  Reverse towne’s  Cephalometric  Water’s view  Xeropadiography

Conventional tomography:
 Orthopantamography  Linear tomography  Corrected tomography

Computed tomography;
Adv. It provide superior osseous anatomical images
without any superimposition than conventional xray.And in different plane. e.g. axial saggital coronal It is good for hard tissue. components.

Disadv. Can’t asses dynamic depiction of soft tissue

( MRI )
Adv. - Doesn’t use ionising radiation. non invasive excellent for soft tissue - very expensive patient discomfort

Disadv.

Arteriography:defect in position or structureof the join disc & its attachment can be determined using arthrography. arthrography is performed by injecting the contrast madia in to the joint space and after it radiograph is taken.

Arthroscopy Electromyography

INTRACAPSULAR DISORDES OF TMJ
1) INTERNAL DEARANGMENT OF TMJ.

2) TMJ ARTHRITIS or DEGENERATIVE JOINT DISEASE

Internal derrangement of TMJ
It is abnormal relation between disc &condyl & articulr eminence. May be asymtomatic or abnormal joint sound. Limitaion mouth opening or pain. Doesn’t affect children less than 5 yrs. Loose disc is most commonly ant. & medially displaced because pull of lateral pterygoid.

Etiology :
Chronic low grade micro trauma e.g. bruxism Direct trauma to mandible Malocclusion Luxiety of joint

Types :
1. Anterior disc displacement.

With reduction.

Without reduction

2)Posterior disc displacement.

Treatment:
1. occlusal splint Stabilization with flat plain, hard condyle Full coverage splint Helps to unload the joint and prevent Further disc displacment. 2) Arthrocentesis (lavage of joint)

 TMJ ARTHRITIS / OSTEOARTHRITIS / DEGENERATIVE JOINT DISEASE
 ⇒ Definition:

Disease articular cartilage and subchondral bone with secondary infection of synovial membrane.

Aetiology:
Primary secondary
Unknown but role of genetic. – chronic microtrauma - metabolic disease

• clinical feature:
 Symptomatic

Asymptomatic

 Unilateral

pain over condyle  Limitation of mouth opening  Crepitus  Feeling of stiffness

• Radiographic findings:
 Narrowing

of joint space  Flattening of articular surface  Osteophytic formation  Anterior lipping of condyle  Presence of ELY’s cyst.(subchondral cyst)

Treatment:
Conservative
-NSAIDs -soft diet -intra articular steroid occlusal splint

surgery
-arthroplasty(removal of osteophyte & erosion area of bone) -high condylectomy-replacment

DISLOCATION OF TMJ
Definition: complete seperation of articular surface with fixation in abnormal position.

Etiology
Intrinsic trauma
•Yawn •Vomiting •Singing •Laughing •Seizure

Extrinsic trauma
• Blow to mandible • During intubation in GA. • Dental extraction

Clinical feature

Bilateral involvement
     

Pain(due to spasm) Hollow in front tragus in bilateral site Lateral pole of condyle is prominent Open bite Protruding chin Difficulty in speech

2. Bilateral involvement
Pain(due to spasm) Hollow in front tragus in bilateral site Lateral pole of condyle is prominent Open bite Protruding chin Difficulty in speech

Management

downward,backward,upward movement.

Manual reduction by

Surgical procedure include:
 Bone

grafting to eminence  Eminence reduction  Lateral pterygoid myotomy.

TMJ ANKYLOSIS
 Definition:

it is Greek word means stiff joint or abnormal mobility or consolidation of joint

Classification:
By kazanzian in 1938
1 based on location. Intra articular extra articular

2. based on type of tissues involvement.
bony fibrous fibroosseus

3. based on extent of lesion. Complete incomplete

Etiology:

  

True ankylosis
direct blow over joint, blow on chin Birth trauma Infection -middle ear cavity infection -acute pyogenic arthritis -otitis media -mastoiditis

Inflammation -Rheumatoid arthritis -Osteo arthritis -Scarlet fever

False ankylosis:
muscular trismus muscular fibrosis myositis ossificans tetany tetanus neurogenic cause drug indused # of zygomatic arch bands of scar tissues

Clinical features:
 Inability

to open jaw  Difficulty in mastication  Compromised oral hygiene & speech  Premature contact of posterior teeth so open bite  retrognathia  retrogenia(weak chin)  Prominent antegonioan notch

Radiographic examination
x-ray for TMJ both in open & closed mouth us taken. In fibrous ankylosis joint space is visible but no movement of condyle is seen where as in bony ankylosis a bony mass is seen in the area of joint with obliteration of joint space.

Management

Aim:

 Removal

of ankylosed mass of bone to mobilise jaw  Reconstruction of joint & maintenance of vertical height of ramus  Prevention of recurrence.  Restoration of occlusion & maintenance of function

Surgical approach to TMJ:
Pre auricular Post auricular End aural Temporal Trans coronal or question mark approach submandibular incision

Techniques:

CONDYLECTOMY: it involve excision of the condyle in cases of partial fibrous ankylosis whre some articular space is still persisting. Disadv. Pseudoarthrosis(flail joint) develop as healing occure.

GAP ARTHROPLASTY:
is a tech. Of resecting segment of of bone between base of the skull and the site of entry of inferior dentel nerveinto manbular ramus area. Disadv. - Creation of pseudo articulation & short ramus risk of ankylosis premature occlusion anterior open bite

INTERPOSITIONAL ARTHROPLASTY: In this tech. Some material interposed between bony fragments for preventing reunion. ~ autogenous material -temporalis fascia -perichondrium -Skin graft -Fascia lata ~ alloplastic material -Acrylic resin -tentanium foil

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