32198621 Temporo Mandibular Joint Disorder Oral Surgery
Transcript of 32198621 Temporo Mandibular Joint Disorder Oral Surgery
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BONY BONY ANATOMYANATOMY
Saggital aspectSaggital aspect
coronal aspectcoronal aspect
Glenoid fossa & articular eminenceGlenoid fossa & articular eminence
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TMJ CORONAL VIEWTMJ CORONAL VIEW
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ARTICULAR CARTILAGEARTICULAR CARTILAGE
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TMJ LATERAL VIEWTMJ LATERAL VIEW
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SOFT TISSUE ANATOMY
TMJ capsuleTMJ ligamentsDisc(meniscus)Synovial membrane
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TMJ LIGAMENTSTMJ LIGAMENTS
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CAPSULAR LIGAMENT CAPSULAR LIGAMENT (LATERAL VIEW)(LATERAL VIEW)
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TMJ WITH TMJ WITH MUSCLE MUSCLE ATTACHMENTATTACHMENT
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TEMPORALIS MUSCLE TEMPORALIS MUSCLE (WITH ZYGOMATIC ARCH & MASSETER MUSCLE REMOVED)(WITH ZYGOMATIC ARCH & MASSETER MUSCLE REMOVED)
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MASSETER MUSCLEMASSETER MUSCLE
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LATERAL & MEDIAL PTERYGOIDLATERAL & MEDIAL PTERYGOID
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Blood supply- Branches from Superficial temporal & Maxillary Artery
Nerve supply- Auriculotemporal & Masseteric Nerve
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TMJ PATHOLOGY – PT’S HISTORYTMJ PATHOLOGY – PT’S HISTORY
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TMJ PATHOLOGY , PATIENT'S HISTORY
Age - Younger-MPDS common Older degenerative disease common
Occupation - Higher class people
H/O pain - MPDS - dull & morning time TMJ pain - Sharp & increased during function
Jaw & joints symptoms
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Oral habit : Bruxism Chewing pattern
Medical history : Rheumatoid arthritis Extraction Trauma H/O : Headache Back pain Ear ache
Family history : Rheumatoid arthritis Osteoarthritis
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CLINICAL EXAMINATION
Facial symmetry Mouth opening TMJ palpation Muscle palpation Dental examination
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MYOFASCIAL PAIN DYSFUNCTION SYNDROME
or MASTICATORY MYALGIA
orCOSTEIN’S SYNDROME
orTMJ ARTHROSIS
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MPDS is a pain disorder, in which unilateral MPDS is a pain disorder, in which unilateral pain is reffered from the trigger points in pain is reffered from the trigger points in myofacial structure, to the muscles of the myofacial structure, to the muscles of the head n neck.head n neck.
pain is constsnt, dull ache I pain is constsnt, dull ache I contrast to sharp shooting , intermittent contrast to sharp shooting , intermittent pain of neuralgias(chronic pain). But the pain of neuralgias(chronic pain). But the pain may range from mild to intolerable. pain may range from mild to intolerable.
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historyhistory Occlusion theory : costen ( 1934 )Occlusion theory : costen ( 1934 ) he reported association of bite closure he reported association of bite closure
(due to loss of posterior teeth) with symptoms (due to loss of posterior teeth) with symptoms like ear pain,sinus pain, decreased hearing, like ear pain,sinus pain, decreased hearing, tinnitus, dizzinus, burning n vertigo n occipital tinnitus, dizzinus, burning n vertigo n occipital headaches(bite raising era)headaches(bite raising era)
Psychophysiologic theory: laskin (1969)Psychophysiologic theory: laskin (1969) he states that psychologic stress leads he states that psychologic stress leads
to myospasm (tranquilizers,muscle relaxants)to myospasm (tranquilizers,muscle relaxants)
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SYMPTOMS OF MPDSSYMPTOMS OF MPDSCARDINAL SYMPTOMS:- CARDINAL SYMPTOMS:- pain or discomfort in head or neckpain or discomfort in head or neckLimitation of the motion of the jawLimitation of the motion of the jawJoint noises-grating , clicking , snappingJoint noises-grating , clicking , snappingTenderness to palpation of muscle of Tenderness to palpation of muscle of
mastication.mastication.Associated symptoms:-Associated symptoms:-Neurologic– tingling , numbnessNeurologic– tingling , numbnessG I track – nausea , vommiting, diarrhoeaG I track – nausea , vommiting, diarrhoeaMusculo skeletal – fatigue, tention, shift jt. PainMusculo skeletal – fatigue, tention, shift jt. PainOtologic – ear pain, dizziness, vertigoOtologic – ear pain, dizziness, vertigo
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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
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6) occlusal splint. stabilization & relaxation splintsAdv. 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
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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.
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DIAGNOSTIC STUDY
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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
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Computed tomography;
Adv. It provide superior osseous anatomical images without any superimposition than conventional x- ray.And in different plane.
e.g. axial saggital coronal
It is good for hard tissue.
Disadv. Can’t asses dynamic depiction of soft tissue components.
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( MRI )
Adv. - Doesn’t use ionising radiation. non invasive excellent for soft tissue
Disadv. - very expensive patient discomfort
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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
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INTRACAPSULAR DISORDES OF TMJ
1) INTERNAL DEARANGMENT OF TMJ.
2) TMJ ARTHRITIS or DEGENERATIVE JOINT DISEASE.
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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.
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Etiology :
Chronic low grade micro trauma e.g. bruxism
Direct trauma to mandible
Malocclusion
Luxiety of joint
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Types :
With reduction. Without reduction
1. Anterior disc displacement.
2)Posterior disc displacement.
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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)
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TMJ ARTHRITIS / TMJ ARTHRITIS / OSTEOARTHRITIS / OSTEOARTHRITIS /
DEGENERATIVE JOINT DISEASEDEGENERATIVE JOINT DISEASE
DefinitionDefinition::
Disease articular cartilage and Disease articular cartilage and subchondral bone with subchondral bone with secondarysecondary
infection of synovial membrane.infection of synovial membrane.
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Aetiology:
Primary
secondary
Unknown but role of genetic. – chronic microtrauma - metabolic disease
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• clinical feature:clinical feature: Symptomatic AsymptomaticSymptomatic Asymptomatic
Unilateral pain over condyleUnilateral pain over condyleLimitation of mouth openingLimitation of mouth openingCrepitusCrepitusFeeling of stiffnessFeeling of stiffness
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• Radiographic findings:Radiographic findings:
Narrowing of joint spaceNarrowing of joint spaceFlattening of articular surfaceFlattening of articular surfaceOsteophytic formationOsteophytic formationAnterior lipping of condyleAnterior lipping of condylePresence of ELY’s cyst.(subchondral cyst)Presence of ELY’s cyst.(subchondral cyst)
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Treatment:Treatment:
Conservative surgery -NSAIDs -arthroplasty(removal of
osteophyte -soft diet & erosion area of bone) -intra articular steroid -high condylectomy-
occlusal splint -replacment
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DISLOCATION OF DISLOCATION OF TMJTMJ
DefinitionDefinition: : complete seperation of articular complete seperation of articular surface with fixation in abnormal surface with fixation in abnormal position.position.
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EtiologyEtiology
Intrinsic trauma Extrinsic trauma
Yawn Blow to mandibleVomiting During intubation in GA.Singing Dental extractionLaughingSeizure
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Clinical featureClinical feature Bilateral involvementBilateral involvement
Pain(due to spasm)Pain(due to spasm) Hollow in front tragus in bilateral siteHollow in front tragus in bilateral site Lateral pole of condyle is prominentLateral pole of condyle is prominent Open bite Open bite Protruding chinProtruding chin Difficulty in speechDifficulty in speech
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2. Bilateral involvement
Pain(due to spasm)Hollow in front tragus in bilateral siteLateral pole of condyle is prominentOpen bite Protruding chinDifficulty in speech
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ManagementManagement Manual reduction byManual reduction by
downward,backward,upward movement.downward,backward,upward movement.
Surgical procedure include:Surgical procedure include: Bone grafting to eminenceBone grafting to eminence Eminence reductionEminence reduction Lateral pterygoid myotomy.Lateral pterygoid myotomy.
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TMJ ANKYLOSISTMJ ANKYLOSISDefinitionDefinition::
it is Greek word means stiff joint or it is Greek word means stiff joint or abnormal mobility or consolidation of abnormal mobility or consolidation of joint joint
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Classification:Classification: By kazanzian in 1938 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
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Etiology:Etiology: True ankylosisTrue ankylosis
direct blow over joint, blow on chindirect blow over joint, blow on chin
Birth traumaBirth trauma
InfectionInfection -middle ear cavity infection-middle ear cavity infection -acute pyogenic arthritis-acute pyogenic arthritis -otitis media-otitis media -mastoiditis-mastoiditis
InflammationInflammation -Rheumatoid arthritis -Rheumatoid arthritis -Osteo arthritis-Osteo arthritis -Scarlet fever-Scarlet fever
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False ankylosis:
muscular trismusmuscular fibrosismyositis ossificanstetanytetanusneurogenic causedrug indused# of zygomatic archbands of scar tissues
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Clinical features:Clinical features: Inability to open jawInability to open jawDifficulty in masticationDifficulty in masticationCompromised oral hygiene & speechCompromised oral hygiene & speechPremature contact of posterior teeth so Premature contact of posterior teeth so
open biteopen bite retrognathiaretrognathia retrogenia(weak chin)retrogenia(weak chin)Prominent antegonioan notchProminent antegonioan notch
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Radiographic examinationRadiographic examination
x-ray for TMJ both in open & closed mouth us x-ray for TMJ both in open & closed mouth us taken.taken.
In fibrous ankylosis joint space is visible In fibrous ankylosis joint space is visible but no movement of condyle is seen where as but no movement of condyle is seen where as in bony ankylosis a bony mass is seen in thein bony ankylosis a bony mass is seen in the
area of joint with obliteration of joint space.area of joint with obliteration of joint space.
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ManagementManagement Aim:Aim:
Removal of ankylosed mass of bone to Removal of ankylosed mass of bone to mobilise jawmobilise jaw
Reconstruction of joint & maintenance of Reconstruction of joint & maintenance of vertical height of ramusvertical height of ramus
Prevention of recurrence.Prevention of recurrence. Restoration of occlusion & maintenance of Restoration of occlusion & maintenance of
functionfunction
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Surgical approach to TMJ:
Pre auricular Post auricularEnd auralTemporal Trans coronal or question mark approachsubmandibular incision
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Techniques:Techniques: CONDYLECTOMYCONDYLECTOMY::
it involve excision of the condyle in it involve excision of the condyle in cases of partial fibrous ankylosis whre cases of partial fibrous ankylosis whre some articular space is still persisting.some articular space is still persisting.
Disadv. Pseudoarthrosis(flail joint) Disadv. Pseudoarthrosis(flail joint) develop as healing occure.develop as healing occure.
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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 ankylosispremature occlusionanterior open bite
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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 -Silastic block