1 / 49

Management of TMJ disorders

Management of TMJ disorders. Part1. Introduction-TMJ. Joints Anatomy Developmental Anatomy Classification Functional/Surgical Anatomy. TMJ Development. The mandible and TMJ develop from the first pharyngeal arch both are innervated by the fifth cranial nerve

winthrop
Download Presentation

Management of TMJ disorders

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of TMJ disorders Part1

  2. Introduction-TMJ • Joints • Anatomy • Developmental Anatomy • Classification • Functional/Surgical Anatomy

  3. TMJ Development • The mandible and TMJ • develop from the first pharyngeal arch • both are innervated by the fifth cranial nerve • (providing both sensory and motor innervation) • By the 6th week of human gestation • Meckel’s cartilage (primary cartilage) extends from the developing ear to approximately the midline

  4. TMJ Development • By the 9th week of human gestation • The rudimentary mandible is formed by “intramembranous ossification”

  5. TMJ Classification • Anatomic Classification: • Diarthrodial= literally means two articulations • a joint that contains the following characteristics • a freely movable joint ( Discontinuous articulation of two bones • bony surfaces are covered with hyaline or fibrocartilage • lined by a synovial lining and contains synovial fluid • Ginglymoid –Joint has hinge like movement component

  6. TMJ Classification • Functional classification: • Compound joint: A joint composed of three or more skeletal elements • Ginglymoarthroidal Joint • Ginglymoid joint that allows hinge like motion (inferior joint space) • Arthroidial joint that allows translator or gliding movement (superior joint space)

  7. TMJ Classification • The mandible functions as a class III lever system • Load is occlusal surface • Fulcrum is formed by TMJ joint • Force is from muscles of mastication

  8. 6 components of TMJ • Osseous Components • Condyles • Articular surface of temporal bone • Soft tissue components • Capsule • Articular Disc • Ligaments • Muscle-Lateral Pterygoid

  9. Bony Anatomy • The articular portion of the temporal bone consists of 3 parts: • GlenoidFossa (aka Mandibularfossa) • Articular eminence • Preglenoid plain

  10. Bony Anatomy • Glenoidfossa • Contains lateral and medial rims • Roof of the fossa is thin and separates the brain from the joint cavity • The articular surfaces of the temporal and condylar bones are covered by Fibrocartilage

  11. Bony Anatomy • Fibrocartilage: • Contains a greater proportion of collagen fibers than hyaline cartilage • has a significant capacity to regenerate and to remodel • Contains few blood vessels • primarily nourished by diffusion

  12. Bony Anatomy • Condyle • Condylar Heads (Paired) • 145-160º angle to each other • Covered by fibrocartilage • Individual Condylar Head • 15-20 mm in diameter • 8-10 mm in A-P dimension • Medial and lateral tubercles provide attachment to the collateral ligaments

  13. Articular Disc • Articular Disc • Dense fibrous connective tissue • Devoid of any blood vessels or nerve fibers(extreme periphery is mildly innervated) • Sagittal Plane • Anterior Band • Posterior Band • Intermediate zone

  14. Articular Disc • During function-Adapts to functional demands • Attachments • Posterior attachment- RetroDiscal tissue • Superiorly- Superior retroDiscal lamina • Inferiorly-Inferior retroDiscal lamina

  15. Articular Disc • The articular Disc • divides the joint into a superior and inferior joint space • Joint space volumes • Classically, • Superior space = volume 1.2 ml • Inferior space = volume 0.9 ml • However, recent arthroscopic studies have suggested • Superior space=0.5 ml • Inferior space = 0.3 ml • This helps to stabilize the Disc during function

  16. Articular Disc • Anterior Attachment • Capsular ligament forms-Superior and Inferior attachments-

  17. RetroDiscal Tissue • RetroDiscal Tissue • “the bilaminar zone” • Highly vascular • Highly innervated tissue • superior retroDiscal lamina • inferior retroDiscal lamina

  18. RetroDiscal Tissue • “superior retroDiscal lamina” • superior aspect of the retroDiscal tissue • Contains elastic fibers • Attaches to the tympanic plate • “inferior retroDiscal lamina” • the inferior aspect of the retroDiscal tissue • Consists of collagen fibers without elastic tissue • Attaches to the posterior margins of the condyle

  19. Anterior region • Superior attachment • Anterior margin of articular surface of temporal bone • Inferior Attachment • Anterior margin of the articular surface of the condyle

  20. Ligaments • 3 primary ligaments: • Collateral ligaments • TMJ capsule • Temporomandibular ligament

  21. Ligaments • Accessory ligaments: • Sphenomandibular ligament • Stylomandibular

  22. TMJ Innervation • Sensory innervation • Primarily from the auriculotemporal nerve (the mandibular branch of the trigeminal nerve) • Other contributing nerves • Masseteric nerve • Deep temporal nerve • Motor innervation to the muscles of mastication • Mandibular branch of the trigeminal nerve

  23. Blood Supply

  24. Case Presentation • CC: 26 years ♀ presents to the OMS clinic with complaint of • left jaw pain • Intermittent right jaw popping and • inability to open her mouth completely • HPI: • Patient volunteers the following information: • Pt reports a h/o intermittent bilateral jaw joint popping and clicking since she was 16 • Approximately 2 years ago her left jaw quit popping and began to hurt more • Since that time her left jaw joint pain has progressively increased • When asked where it hurts she points to her left TMJ area

  25. Examination of TMJ • Interview • Examination of Masticatory system • TMJ examination • Digital Palpation • Mandible is stationary • Dynamic movement • Check for Pain and tenderness • Sounds • Restrictions

  26. Digital Palpation • Method-step1 • Simultaneously place fingers on both joint areas • Ask the patient to open and close a few times for confirmation • Lateral poles are palpated passing downwards and forward across the articular eminence • Apply medial force and patient to report any symptoms • Record pain on a scale of 1-10

  27. Digital Palpation-Step2 • Ask the patient to open his/her mouth • Rotate the fingers posteriorly • apply gentle force to the posterior aspect • Helps in evaluating any posterior capsulitis or retroDiscitis • Record the areas of tenderness and which part of the opening and closing cycle is it experienced

  28. Sounds • Clicking-distinct sound • Crepitation- scraping or grating sound • Usually associated with Osteoartheritis • Changes in articular surfaces of joint • Louder sounds (sometimes referred to as ‘POP’)

  29. Joint Restrictions • Normal range of motion-straight and symmetric • Interincisal-45mm • Protrusive -10mm • Lateral-10mm • Types- • Extracapsular • Intracapsular

  30. Radiographic Evaluation • Panoramic • Bony anatomy, overall architecture of joint • Tomograms • TMJ Arthrography (Injecting contrast material) • Allows intra-articular Disc visualization • Presence of perforations adhesions

  31. Radiographic Evaluation-contd. • Computed Tomography • Hard and soft tissue morphology • Most accurate assessment of Bony components • MRI • Best for soft tissue elements of TMJ • Dynamic join functions are visualized • Advantage-No ionizing radiation is used • Nuclear Imaging • IV injection of technetium99( Gamma emitting Isotope)

  32. Classification of TMJ disorders • MPD • Disc Displacement • Degenerative Joint disease • Systemic Arthritic Conditions • Chronic recurrent dislocation • Ankylosis • Intrcapsular /Extracapsular • Neoplasia • Infections

  33. Myofacial Pain Dysfunction • Most common cause of Masticatory Pain • Source-Muscular • Muscles of mastication –tender • Abnormal muscle function • Hyperactivity • Clenching or Nocturnal Bruxism • Etiology- Multifactorial ( bruxism,stress, Anxiety, faulty occlusion)

  34. Myofacial Pain Dysfunction • C/F: • Diffuse pain in preauricular area • May involve muscles of mastication • Nocturnal Bruxism • Pain is increased iin the morning • Decreased jaw opening while chewing • Bitemporal headaches • TMJ’s are non tender on palpation • Range of mandibular movement is reduced • Wear facets on teeth

  35. Disc Displacement Disorders(Internal derangement) Anterior Disc displacement with reduction Anterior Disc displacement without reduction

  36. Wilkes Classification • Early Stage • Stage 1 • Mild Disc displacement with normal Disc morphology • Reduction relative to condyle with mouth opening • Intermediate stage • Stage 2 • Mild to moderate Disc displacement and deformity • Reduction with opening • Stage 3 • Disc displacement, deformity and non reduction of Disc with opening • Responds best to surgery • Late stage • Stage 4 • Severe displacement, deformity, shortening or rarely elongation • Non reduction of Disc • Stage 5 • Perforation of Disc attachements • Severe derangement of joint • Regressive remodeling/ osteoartheritis

  37. Normal Disc Condyle relationship

  38. Anterior Disc displacement with reduction • Disc position • Mouth closed -anterior and medial to condyle • Opening- condyle moves over posterior band of Disc and then returns to normal condyle Disc relationship(i.e. resting on intermediate zone) • Closing-condyle slips posteriorly , rests on retroDiscal tissue, Disc returns to anterior and medial displaced position

  39. Anterior Disc displacement with reduction

  40. Anterior Disc displacement with reduction • Clinical features • Joint tenderness • Clicking –during opening • a closing click (reciprocal click)can also be elicited • MRI best demonstrates

  41. Anterior Disc displacement without reduction • Condyle does not translate anteriorly to its full extent • No clicking (lack of translation of condyle over posterior aspect of the Disc) • Limitation of mouth opening • Deviation of mandible to affected side • Decreased lateral excursions to contra lateral side

  42. Anterior Disc displacement without reduction

  43. Degenerative Joint Disease(DJD) • Anatomic findings- • Irregularities in Disc • Perforations Severely damaged Discs • Clinical features • Pain associated with Clicking • Limitation in mouth opening • Radiographic features • Surface erosions • Decreased joint space • Flattening of condylar head • Irregularities in Mb fossa and articular eminence

  44. Systemic Arthritic conditions(SAC) • Rheumatoid arthritis • Inflammatory process • Radiographic Features- • Erosive changes in anterior and posterior condylar head • Differences between DJD and SAC( RA, lupus) • RA-bilateral joint involvement • RA-Earlier onset than DJD

  45. Subluxation • Hyper mobility • Cause- • Anatomy-short posterior slope articular eminence followed by a longer ,flatter anterior slope • Spontaneous Dislocation • Mouth is opened beyond its normal limit • Mandible locks • Patient cannot close the mouth

  46. Ankylosis • Intracapsular • Fusion of condyle, Disc, Fossa Complex • Partial reduction to complete immobility • Etiology-Trauma***,Previous surgical treatment, Rarely infections (otitis media) • C/F-Resticted Jaw opening • Deviation to affected side • Fibrous Ankylosis-jaw opening is present • Bony Ankylosis- No movement • Extracapsular • Condylar hyperplasia • Enlarged cornoid process

  47. Bio-model of Condylar hyperplasia

More Related