TEMPEROMANDIBULAR JOINT DISORDERS

Guided by: Dr.Anish Tiwari, Dr.Adarsh Desai, Dr.Ravi Kalola, Dr.Nirav Patel.

Prepared By: Krupa Chudasma(13), Noori Dalwadi(14), Meera Dobariya(15), Prianka Dodia(16)

ANATOMY• THE TEMPOROMANDIBULAR JOINT IS ALSO KNOWN AS THE

CRANIOMANDIBULAR JOINT or BILATERAL DIARTHROIDIAL.

• IT IS THE ARTICULATION BETWEEN THE SQUAMOUS PART OF THE TEMPORAL BONE AND THE HEAD OF THE MANDIBULAR CONDYLE.

• IT IS ALSO CONSIDERED AS COMPLEX JOINT BECAUSE IT INVOLVES TWO SEPARTE SYNOVIAL JOINT, IN WHICH THERE IS A PRESENCE OF INTRACAPSULAR DISC OR MENISCUS.

THE TMJ ARTICULATION CONSIST OF:

• GLENOID FOSSA• ARTICULAR EMINENCE• CONDLYE• SEPARATING DISC• JOINT FIBROUS CAPSULE• EXTRACAPSULAR LIGAMENTS

ARTICULATORY SYSTEM• COMPRISES OF

• Temporomandibular joint• Masticatory and accessory muscles• Occlusion of teeth

• The function is governed by sensory and motor branches of the third division of trigeminal nerve.

• MANDIBULAR FOSSA(GLENOID)• IT HAS AN ANTERIOR ARTICULAR AREA BY THE INFERIOR ASPECT OF TEMPORAL SQUAMA.• THE FOSSA IS LINED BY A DENSE AVASCULAR FIBROCARTILAGE.

• ARTICULAR EMINENCE• IT SEPARATES THE ARTICULAR SURFACE OF THE FOSSA LATERALLY FROM THE TYMPANIC PLATE.• THE EMINENCE IS COVERED BY DENSE, COMPCT, FIBROUS TISSUE THAT CONSISTS PRIMARILY OF

COLLEGEN WITH AFEW FINE ELASTIC FIBERS

• TMJ CAPSULE• IT IS A THIN SLEEVE OF FIBROUS TISSUE INVESTING THE JOINT COMPLETY• IT IS A FUNNEL SHAPED CAPSULE,WHICH BLENDS WITH THE PERIOSTEUM OF THE MANDIBULAR

NECK AND ENVELOPS THE MENISCUS

TEMPOROMANDIBULAR LIGAMENTS• IT REINFORCE THE TMJ CAPSULE • IT EXTENDS DOWNWARD & BACKWARD FROM THE ARTICULAR EMINENCE

TO THE EXTERNAL AND POSTERIOR SIDE OF THE CONDYLAR NECK• ITS POSTERIOR FIBER ARE UNITED WITH THE CAPSULAR FIBERS • THIS LIGAMENT IS COMPOSED OF COLLAGENOUS FIBERS THAT HAVE

SEPIFIC LENGTH AND POOR ABILITY TO STRETCH, HENCE IT MAINTAINS THE INTEGRITY AND LIMITS THE MOVEMENT OF TMJ

• IT MAINLY LIMITS THE ANTERIOR EXCURSION OF THE JAW AS WELLAS PREVENTS POSTERIOR DISLOCATON , ALSO CALLED CHECK LIGAMENT.

• SPHENOMANDIBULAR LIGAMENT

• A FLAT BAND ARISING FROM THE APHENOID SPINE AND PETROTYMPANIC FISSURE, RUNS DOWNWARDS AND MEDIAL TO THE TMJ

• INTERNAL MAXILLARY ARTERY AND AURICULOTEMPORAL NERVE LIES B/W IT AND MANDIBULAR NECK

STYLOMANDIBULAR LIGAMENTIT IS DENCE THICK BAND OF THE DEEP CERVICIVAL FASIA EXTENDING FROM THE STYLOID PROCESS TO THE MANDIBULAR ANGLE.

ARTIULAR DISC/ MENISCUS• THE MENISCUS DIVIDES THE TWO ARTICULAR SPACE INTO TWO COMPARTMENT

• LOWER OR INFERIOR COMPARTMENT- condylodiscal complex b/w the condyle and the disc

• UPPER OR SUPERIOR COMPARTMENT – b/w disc and the glenoid fossa.

• The disc is biconcave in the sagital section.• The superior surface is concavoconvex to match the anatomy of the glenoid

fossa.• The inferior surface is concave to fit over condylar head• The disc blends medially and laterally with the capsule, which is attached to the

medial and lateral poles of the condyle.• Anteriorly the disc is attached to the articular eminence above & to the articular

margin of the condyle below. • Posteriorly disc is attached to the posterior wall of glenoid fossa

• The disc is a meshwork of firmly woven avascular fibrous connective tissue & it is also noninnervated with possible exceptions around its periphery.

• These collagen fibers impart flexibility to the disc.• The disc is designed to transmit the forces generated through the condyle

to the articular eminence.• It promotes lubrication energy absorption and joint range of motion. It acts

as a main shock absorber enabling the articulating bones to move against each other with minimum friction and heat production.

• Disc has a very little potential for repair after inult.

BLOOD SUPPLY • Lateral aspect is supplied by

superfical temporal branch of the external carotid artery.

• Rich vascular supply to the deep and posterior aspect of retrodiscal capsular part by deep auricular, posterior auricular & masseteric branches of the internal maxillary artery

• Vascular supply to the lateral pterygoid muscle also supplies to the head of the condyle by penetration of numerous nutrient foramina vessels

NERVE SUPPLY• THE MANDIBULAR NERVE, THE THIRD

DIVISION OF THE FIFTH CRANIAL NERVE INNERVATES THE JAW JOINTS:-

• The largest is the auriculotemporal nerve which supplies the posterior, medial and lateral part of the joint

• Masseteric nerve• A branch from the posterior deep

temporal nerve, supply the anterior parts of the joint

MOVEMENTS• The movements of tmj are manifold. It is ginglimus diarthroidai type of

joint, as it sis capable of rotating around more than one axis and is capable of translatory movement.

• MUSCLE FUNCTION- The functions of the muscles of mastication in jaw movement are coordinated and balanced by normal muscle tone.

• The muscle of mastication (medial and lateral pterigoid,masseter, buccinator, mylohyoid, temporalis & anterior belly of the digastric) are assisted by the suprahyoid and digastric muscle.

• JAW OPENING It is dominated by daigastric muscle contraction, which depress the body of the mandible. This action is assisted by the suprahyoid, sternohyoid and geniohyoid muscles.

• JAW CLOSURE It is accomplished by the simultaneous contraction of the masseter, medial pterigoid muscles.

• PROTRUSIVE MOVEMENT- It requires equal simultaneous contracture of lateral and medial pterygoid muscle.

• RETRUSION -It is brought about by posterior fibers of temporalis muscles, assisted by middle and deep parts of the masseter, digastric and geniohyoid muscles.

• LATERAL MOVEMENT- These are carried out by unilateral contracture of medial and lateral pterygoid of each side acting alternatively.

TEMPOROMANDIBULAR JOINT DISORDERS CLASSIFICATION

• Intra –articular origin or intrinsic disorder• Extra –articular origin or extrinsic disorder

DISORDER DUE TO EXTRINSIC FACTORS• MASTICATORY MUSCLE DISORDER

• Protective muscle splinting• Masticatory muscle inflammation• Masticatory muscle spasm

• PROBLEMS DAT RESULT FROM EXTRINSIC TRAUMA• Traumatic arthritis• Fracture• Internal disc derangement• Tendonitis• Contracture of elevator muscle

DISORDER DUE TO INTRINSIC FACTORS• TRAUMA

• Dislocation, subluxation• Haemarthrosis• Intracapsular fracture, extracapsular fracture

• INTERNAL DISC DISPLACEMENT• Anterior disc displacement with reduction• Anterior disc displacement without reduction

• ARTHRITIS• Osteoarthritis• Rheumatoid arthritis• Juvenile rheumatoid arthritis• Infectious arthritis

• DEVELOPMENTAL DEFECTS• Condylar agenesis or aplasia- unilateral/bilateral • Bifid condyle • Condylar hypoplasia• Condylar hyperplasia

• ANKYLOSIS• NEOPLASM

• Benign tumours• Malignant tumours

DIAGNOSIS OF TMJ DISORDERS

HISTORY• History of onset, duration, frequency & dental treatment are

important to assess the acute or chronic nature of the disease.

• Factors like pain, click or dysfunction are to be considered while eliciting the history.

• History of trauma & history of dental treatment can usually pinpoint the etiology of the disease.

CLINICAL EXAMINATION• INSPECTION

• DENTAL EXAMINATION

• OCCLUSAL EVALUATION

• RANGE OF MANDIBULAR MOVEMENT

• PALPATION

• NEUROLOGICAL TESTS

• AUSCULTATION

INSPECTION• Interincisal distance on mouth opening• Facial asymmetry• Deviation of mouth on opening or closing• Preauricular swelling• Occlusal cant• Malocclusion• Occlusal derangements• Improper dental restoration or prosthesis• Attrition of teeth decreasing vertical dimension

DENTAL EXAMINATION• Bruxism-attrition of teeth• Cheek or lip ridges caused by trapping of mucosa during clenching

habits• Any premature occlusal contacts or high points in restoration should

be checked for degenerative condition of TMJ

OCCLUSAL EVALUATION• Angle’s classification (Class I, Class II,

Class III)• It provides information about occlusal

relationship, freeway space, overjet & overbite, prosthesis, the evidence for bruxism or other oral habits & their possible effects on dentition (attrition and wear facets) , periodontium or other oral structures

• No. of missing teeth , loss of posterior occlusal contact predispose the TMJ to degenerative joint disease

RANGE OF MANDIBULAR MOVEMENTS• The distance b/n the incisal edges of uppar & lower teeth is measured

together with overjet & overbite normally,35-50mm• Lateral motion 7-10mm to both right & left• Normal protrusive range is 7-10mm• Subluxation or recurrent dislocation of one or both condyles can be

determined by abnormal palpation during movement

• Limitation may be due to: -contracture of one or more of muscles associated with jaw closure -nonreducing anterior displacement of articular disc(closed lock) -coronoid process interference -haematoma or infection -fibrous ankylosis or scleroderma

PALPATION• Tenderness suggests the presence of - fracture - synovitis - capuslitis of the joint

• Palpated for evidence of enlargement (muscle,mandible) & movement of disc(hypermobility)

• Overlying skin is checked for temperature and consistency in case of inflammatory condition

Muscle tenderness• Masseter – palpated with finger & thumb• Temporalis – examined while the patient is clenching the teeth and at the

same time, attempting to move the jaws sideways• Lateral pterygoid – palpated with a finger pushed into the retromolar

area of the maxilla• Indicated in case of muscle related disorders( myospasm ,myalgia,

myofascial pain dysfunction syndrome)

NEUROLOGICAL TESTS• Trigeminal nerve supplies sensation to the superficial and deep

structures of head and face and motor function to the muscles of mastication

• Sensory nerve activity is assessed by applying pressure, cotton wool and pin-pricks to the distribution areas of the trigeminal nerve which helps in diagnosing myofascial pain

AUSCULTATION• Noise is assessed by stethoscope and classified as either click (closed

click or open click) or crepitus though it may be difficult to determine whether a noise is from one joint or both

SPECIAL INVESTIGATIONS• RADIOGRAPHIC EXAMINATION• LABORATORY INVESTIGATION• ELECTROMYOGRAPHIC INVESTIGATION• DRUGS• OCCLUSAL SPLINTS• INTERMAXILLLARY FIXATION• LOCAL ANAESTHESIA

RADIOGRAPHIC EXAMINATION• CT SCAN - In TMJ disorders involving articulating surface that include

hard tissues• MRI & ARTHROGRAPHY – In TMJ disorders including the disc

LABORATORY INVESTIGATION• Indicated in case of TMJ disorders where primary disease are

diagnosed by - biochemical & serological tests• E. g - gout -infectious arthritis/suppurative arthritis (TB , syphilis) -rheumatoid arthritis

ELECTROMYOGRAPHIC INVESTIGATION

• Use of electronic instruments or devices helps in monitoring the activity of disordered TMJ

• E.g. -surface electromyography(EMG) -thermography -sonography -mandibular kinesiology(jaw tracking)

DRUGS• Antinflammatory agents• Tranquilisers• Muscle relaxants• Antidepressants are used in case of myofascial pain dysfunction syndrome (MPDS)

where diagnosis of root cause is very difficult

OCCLUSAL SPLINTS• Used as a test to diagnose MPDS• In dentulous patients, splint may be placed over the abraded teeth to check out the

etiology• In full denture wearers, occlusal splint may be used to establish/detect whether over

closure is contributing to an osteoarthrosis (osteoarthritis)

INTERMAXILLARY FIXATION• IMF - Used when there is severe pain of uncertain origin - It relieves pain if the source is TMJ (condylar fracture ) or

masticatory muscle (prevents overstretching of muscles)

LOCAL ANAESTHESIA• When pain is suspected as arising from an area

of muscle, injection of small amount of LA into respective muscles is advised to establish the diagnosis

• E.g. Injection in the masseter muscle may be indicated to detect myospasm of masseter ; thus this test should be correlated with clinical findings, signs & symptoms

Structural and developmental disorders of the condyle

Developmental disorder

1) Condylar hyperplasia: It is condition of mandibular condyles creating overgrowth of the

mandible. Bilateral: can causes progressive prognathism. Unilateral: can causes facial asymmetry & articular disc dislocation. Three type (obwegeser & makek):-i. Hemimandibular hyperplasia: enlargement of the condyle, Condylar neck,

ramus, body, with tilting of the occlusal plane.ii. Hemimandibular enlargement: condyle neck enlargement, displacement

of the ramus without tilting the occlusal plane.iii. Condylar hyperplasia: only hyperplastic condyle with no associated

mandibular changes.

Two pattern of overgrowth

Condyle itself may become enlarged

Associated with lengthening of ramus

Open bite on affected side

Asymmetry of mandible

condyle is of normal size & shape

Excessive growth at cartilage-bone interface

Elongation of condylar neck

Shift of mandibular midline to the contra lateral side & crossbite

Radiograph: standard multiview cephalometric films, CT scan, MRI, bone scan etc.Treatment: Condylectomy to ensure removal of the growing cartilage.CondyloplastyOrthognathic procedure for correction of facial asymmetry.

2) Hemimandibular elongation: Clinical features:Horizontal displacement of the mandible & chin towards the

unaffected side.Mild mandibular protrusion.Lip line slopes down towards the affected side.Lateral crossbite on the unaffected side.Occlusal plane sometimes slopes upward to affected side. In severe cases, a lateral open bite is occasionally seen on the

affected side.The displacement of the midline is greater at the anatomical mid-

chin than at the incisor midline, so that there appears to be an apical drift of the incisors towards the unaffected side.

Radiograph: Posteroanterior view: Orthopantomograph: demonstrates the length & any gross enlargement of the

neck of condyle. Scintigraphy: during the period of active growth demonstrates hyperactivity in the

condyle of the affected side.Treatment: In case of hemimandibular elongation condylar surgery is necessary. It is advisable to wait till the cessation of mandibular growth before surgery. In the fully developed condition any presurgical orthodontics, spatial correction is

required. In the simpler cases where there is no cant of the occlusal plane, a bilateral

mandibular ramus osteotomy is usually sufficient to achieve a resonable result. In addition a genioplasty is sometimes necessary to achieve symmetry of the chin.

In patient with occlusal cant occlusal plane can be corrected by Le Fort I osteotomy in addition to the mandibular surgery.

Hemimandibular elongation

Hemimandibular hyperplasia• This condition is characterized by a 3D enlargement of one side of the

mandible,thus there is enlargement of the condyle,the condylar neck & the ascending ramus & the body

• The abnormal growth terminates precisely at the symphysis,giving rise to a sharp ‘step’ in the mandible at that site & justifying the term hemimandibular hyperplasia

• 1. one side of the face appears to be enlarged• 2.unilateral ‘bowing’ of the inferior border of the

mandible is seen on the affected side• 3.lipline slopes downward on the affected side

• 4.gross occlusal discrepancies like lateral open bite on the affected sid,overeruption of posterior theeth in the maxilla with occlusal cant & increased vertical maxillary height on the affected side may be seeen

• 5.Associated TMJ pain symptoms may be present

Radiographically,• Entire hemimandibleon the affected side is enlarged & the inferior

dental canal is displaced towards the lower border.the OPG demonstrates a pathognomonic appearance.

• 1. the elongation of ascending ramus(unilateral)• 2.elongation & thickening of the condylar neck(unilateral)• 3.an irregular & deforming enlargement of thr condyle(unilateral)

• 4.the angle is characteristically rounded off(unilateral)• 5.typical ‘bowing’ of the inferior border of the mandibular body-

(unilateral)• 6.increased height of the body of thr mandible(unilateral)

3) Condylar hypoplasia and aplasia:it is characterised by facial deformity expressed on the affected

side by a short mandibular ramus.May be unilateral or bilateral.a) Unilateral condylar hypoplasia:-o Clinical feature:• Shortening of mandibular vertical height occurs on the affected

side.• A midline shift towards the same side.• Shifting of the chin towards the shorter side of the face.• Deviation of the mandible on mouth opening.• Occlusal cant.

oCause:• Condition may occur from birth due to pharyngeal first or second arch

malformation.• It may result from trauma, infection or irradiation during the growth period.• Syndromes with hemimandibular hypoplasia as a component are: Goldenhar-Gorlin syndrome. First and second branchial arch syndrome. Craniofacial microsomia. Dyke-Davidoff-Masson syndrome. Femoral-facial syndrome.

Condylar hypoplasia and aplasia

b.) Bilateral condylar hypoplasia:• When mandibular shortning occurs on the both sides, it results in micrognathia or

small mandible.• Bird like face, retruded chin with a small mandibular arch characterises this condition.• When this occurs congenitally, it causes respiratory distress due to obstruction of the

pharyngeal airway by falling back of the tongue.• Bilateral condylar hypoplasia is seen in:Pierre Robin syndrome.Treacher Collins syndrome.Nager’s syndrome.Townes-Brocks syndrome.Branchio-oto-renal syndrome.Branchio-oculo-facial syndrome.Stickler’s syndrome.

Treatment: Should be treated earlier in the growing period itself to avoid secondary

deformities.this can be achieved either by:• Growth center transplantation.• Graft.• Distraction osteogenesis.• Orthognathic surgery.

Bilateral condylar hypoplasia

Acquired disorder

1.) Traumatic arthritis:Any traumatic incident involving the TMJ may lead to acute arthritis.Chronic trauma to the joint due to trauma from occlusion is also responsible

for osteoarthrosis.Traumatic arthritis characterised by tenderness of the affected joint and

restriction of movement, which cause the mandible to swing to the affected side on opening.

There may be oedema around the joint and restricted mouth opening due to pain presenting as classic trismus.

Treatment of trismus is usually treating the cause followed by physiotherapy.Long term trismus may require surgical removal of the coronoid processes

and the temporalis muscle attachment, followed by physiotherapy.

2.) Osteoarthritis:It is a chronic noninflammatory and degenerative disease affecting the

articular cartilage of joints.Clinical feature: Usually 5th decade-slow onset of disease with mild symptom. Usually one TMJ is involved. Women are more likely to be affected with TMJ involvement. Pain in the joint and muscles of mastication, causing limitation of mandibular

motion. Joint noises, especially crepitus. Osteophyte formation and marginal bone thickening leads to palpable masses

over preauricular region.

Treatment: Moderate exercise and physical therapy should be started to strengthen the

musculature supporting the joints. NSAIDs to reduce pain. In severe case, thermal therapy can be obtained with ultrasonography and

infrared heat. Orthopedic procedures(debriding loose bodies, osteotomy and prosthetic

replacement) should be reserved for patients with retractable pain.

3.) Rheumatoid arthritis(RA):It is autoimmune disease predominantly affecting

disarthroidal joint.It can affect the joint at any age.Juvenile rheumatoid arthritis(Still’s disease) may be of

varying severity.Etiology:Genetic susceptibility.Autoimmune response.increased HLA-DR4 antigen, correlated with increased levels

of rheumatoid factor.

Clinical feature:Intermittent pain, swelling and progressive limitation of joint

motion.Characteristically, the joint of the hands and feet are first

affected.Preauricular joint pain on chewing and moving.Advanced disease leads to decreased range of motion and

stiffness.Decreased bite force, muscle tenderness.Clicking,crepitus and tenderness of the joint on paplation.Progressive class II malocclusion develops.

Treatment: a.) Conservative method:Antiinflammatory drugs(salicylates, NSAIDs,

corticosteroids), soft diet, avoiding extreme jaw movement.If NSAIDs are ineffective, disease modifying antirheumatic

drugs like hydroxychloroquine, penicillamine or the cytotoxic agents like methotrexate or cyclophosphamide are considered.

In juvenile RA : Methotrexate.

b.)Surgical methods:High condylectomy .Arthroplasty for total joint reconstruction using alloplast.Synovectomy.

4.) Psoriatic arthritis:It resembles rhemumatoid type , but it is associated with psoriasis, a

dermatologic disease.Etiology: Genetic component. Presence of HLA-B27 antigen.Clinical feature: TMJ involvement is described as episodic, sudden and usually

unilateral. Limitation of mandibular movements. Morning stiffness, crepitus, eventual loss of interincisal opening. In advanced disease, ankylosis can occur.

Treatment: Systemic treatment should be undertaken. Reduce loading on the joint. In severe cases, immunosupressive agents such as Methotrexate have

been used.

5.) Ankylosing spondylitis (Marie-Strumpell disease):This is a chronic inflammatory disease involving the

articulation of spine and adjacent soft tissue.It has high risk ratio of male:female (8:1).Clinical feature:Symptoms are due to imperfect head posture caused by

the vertebral lesions.The most common complaints are of pain, stiffness,

decreased range of motion and eventually ankylosis.Extra-articular manifestations such as iritis, uveitis, and

cardiac symptoms are commen in patient with TMJ involvement.

Treatment:The load must be reduced across the joint by the use

of acrylic splints.The drug with proven efficacy is sulphasalazine.Surgical intervention should be limited to those

patients with severe crippling disease.

MYOFACIAL PAIN DYSFUNCTION SYNDROME

Synonym: Facial arthromyalgia, MPDS, temporomandibular joint dysarthrosis, mandibular pain dysfunction syndrome & temporomandibular joint arthrosis, Costen’s syndrome.

Definition: “It is pain disorder, in which unilateral pain is referred from the trigger points in myofascial structures, to the muscles of the head & neck. Pain is constant, dull in nature, in contrast to the sudden sharp, shooting, intermittent pain of neuralgias(chronic pain).but pain may range from mild to intolerable.”

PathophysiologyMPDS can be visualized as a vicious cycle of several contributing factors

such as:• Muscular hyperfunction.• Physical disorders.• Injuries to the tissues.• Parafunctional habits.• Disuse.• Nutritional problems.• Physiological stress.• Sleep disturbances.

It is very difficult to know the initiating point, since it arises from the multifactorial origin.

So etiology can be of 3 major type:1. Psycholgic or central etiology.2. Occlusal or peripheral etiology.3. The third group is recently considered is due to intrinsic joint disorder

etiology. Psychogenic cause: it is possible that certain psychologically

unbalanced individuals, due to unusual habits, muscular disturbance leading to occlusal disharmony & thereby affecting the TM joints.

oPersistent tension relieving oral habits:• Pipe smoking.• Sleeping on stomach with the mandible supported by the forearm.• Teeth clenching.• Teeth grinding/bruxism.• Lip licking.• Jaw thrusting.• Nail biting.• Tongue thrusting.• Pencil/pen biting.• Constant chewing of tobacco & chewing gum.

Occlusal disharmony: it can be;oInherent malocclusion.oAcquired malocclusion.oIatrogenic occlusal disharmony.

Pathological changesTMJ:• No changes can be detected clinically. In early lesions, there is loss of the

usual smooth surface zone & development of an uneven surface.• In later stages there is total loss of the entire amorphous layer & the

superficial collagen masses consist only of small diameter fibrils.• Disorganisation of the articular surface occurs in case of more severe &

prolonged disorder.

Muscles: • Pathological changes in muscles are indefinite.• Raised intramuscular pressure attributing to oedema.• Increased blood flow.• Degranulating mast cells seen in histological examination of painful

muscle.

SymptomsPain: this can be localised to the joint or referred to the head, neck or

shoulders. Pain is mostly dull aching.Limitation of mandibular movement: mouth opening is limited, which

may be either constant or intermittent.Muscle hyperactivity.Abnormal muscle activity.Clicking: mostly bilateral.Locking.

Signs Joint tenderness: tenderness of the joint when palpated either in the

preauricular region or from within the external auditory meatus.Muscle tenderness: tenderness of the masticatory muscles may be

noted, especially the masseter, anterior part of temporalis & lateral pterygoid.

Abnormalities of mandibular movement: lateral deviation are diagnostically helpful.

Radiography When degenarative disease is not suspected, standered lateral

transcranial views help to reveal that no unsuspected pathological feature is present.

When degenerative disease is suspected, then a special view such as transpharyngeal might be needed.

Tomography will also helpful.Function of the joint can be assessed by arthrography(injection of

radiopaque fluids) or by studying images during movements.

Treatment Two type i.) conservative management.ii.) surgical management.

Conservative management. 1.) Placebo: by using splints and by mock adjustment of the occlusion.2.) Reassurance: doctor/patient relationship is very important for the

success of the treatment. 3.) Occlusal correction: patient should perform bilateral mastication. Any

dental pain, missing teeth should be treated. Habits can be corrected by exercises.

4.) Soft diet: To reduce loading forces on joint and reduce muscle activity.5.) Splints: It inactivates facial muscles, decompresses intracapsular tissue,

establishes balance occlusal plane, stabilises the disc and restore the vertical dimension.

Types

Stabilisation splint Resilient splint(soft splint) Bite plane splint

Anterior bite splint Full occlusal splint

Pivot splint Mandibular repositioning splint

6.) Drugs:

• NSAIDs are helpful in reducing pain and inflammation.• Antiinflammatory effect of corticosteroids is greater than NSAIDs. Can be given

intra-articular and orally.• Anxiolytics to reduce anxiety.• Muscle relaxants:Methocarbamol, Chlorzoxazone.• Antidepressants: Tricyclic antidepressant.7.) Thermal agent: They help in decreasing pain, increasing muscle relaxation.a.) Superficial moist/dry heat.b.) Ultrasonography-deep.8.) Intermaxillary fixation.9.) Cold: Cold can be used to control inflammation by application of ice packs to

TMJ.

10.) Iontophoresis: It is a battery-powered system used to deliver water soluble ionizing drugs through skim.

11.) TENS: Transcuteanous electric nerve stimulation provides symptomatic pain relief.

12.) Home exercise programme for hypomobility.13.) Pressure-point techniques.14.) Muscle injection: it is given to inactivate the trigger point, reduce

muscle pain and enhance muscle relaxation.15.) Intra-articular injection: Mostly steroid injection is used.

Surgical management1. Arthrocentesis and lavage.2. Arthroscopy.3. Disc repositioning.4. Disc removal.5. Disc removal and • Autologous graft disc replacement.• Alloplastic disc replacement.6. Condylotomy.7. Condylectomy.

TMJ ANKYLOS

IS

INTRODUCTION• Temperomandibular joint ankylosis(TMJ) is a

unique condition of the joint that restricts the joint mobility progressively thus limiting the jaw moments.

• Ankylosis is greek word meaning ‘stiff joint’.• The jaw function gets affected because of

immobility of the joint.• Hypomobility to immobility of the joint can lead to

inability to open the mouth from partial to complete.

• Onset is usually seen before the age of 10 years.

AETIOLOGY1.Trauma At birth (with forceps) Haemarthrosis Blow to the chin (causing haemarthrosis) Condylar fracture Congenital

Trauma

Haemarthrosis

Haematoma organisation

Activate the bone healing process

Fibrosis

Induced osteoblastic differentiation

May fascilitate the calcification process

Gradual bone formation from the disrupted periosteum

Mechanical destruction of surfaces of condyle and glenoid fossaDisc removal

Appropriate environment for bone formation

2.Infections and InflammatoryA.PRIMARY INFLAMATION OF THE JOINT Tuberculosis Staphylococcus aureus Neisseria gonorrhoeae Haemophilus influenzaB.SECONDARY INFLAMMATION Mastoiditis Otitis media

3.Arthritis Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis

4.Others Malignancies Post radiology Post surgery Prolonged trismus

5.Rare causes Polyarthritis Measles

PATHOPHYSIOLOGY

CLASSIFICATION OF ANKYLOSIS• LOCATION1.Intra articular2.Extra articular• TYPES OF TISSUE INVOLVED1.Bony 2.Fibrous3.Fibro osseous• EXTENT OF FUSION1.Complete2.Incomplete

A.KAZANJIAN CLASSIFICATION1.Extra articular or false ankylosis- due to pathological changes in the structures surrounding the TMJ causing limitations in mouth opening .Radiographic findings evaluate normal appearing TMJ and joint space.2.Intra articular or true ankylosis- caused by the fibrous or bony adhesions between the articular surfaces of the mandibular condyle and glenoid fossa.The diagnosis of true ankylosis in a patient with limited mouth opening is evident by condylar deformation ,loss of joint spaces and abnormal bone formation in and around the TMJ in the radiographs.

B.SAWHNEY CLASSIFICATIONFor classification of primary ankylosis on basis of

radiographic evidence1.True (intra articular) i)Type I -the condyle is medially angulated and associated with a deformed articular fossa together with a mild to moderate amount of new bone formation. ii)Type II - no recognisable condyle or fossa but instead a large mass of new bone extending from the ramus to the base of the skull. iii)Type III - a medially displaced fracture dislocation with bone bridging the mandibular ramus to the zygomatic arch. iv)Type IV - the joint architecture is replaced completely by bone with fusion of the condyle ,sigmoid notch and coronoid process to the zygomatic arch and glenoid fossa.2.False (extra articular)

Type I Type II

Type III Type IV

Modification of SAWHNEY classification for REANKYLOSIS(as in reankylosis after gap anthroplasty have very little resembalance to normal bone anatomy)

Type I – fibrous ankylosis ,reduction in joint space with clear demarcation of the borders of the temporal and condylar component.Type II - bony ankylosis between the condylar region and temporal bone ,without involving the coronoid process or the sigmoid notch.Type III a – ankylosis between condyle and temporal bone with hyperplasia of the coronoid process without ankylosisType III b – ankylosis involving the coronoid and the condylar region without obliteration of the sigmoid notch.Type IV – complete bony union of the condyle and coronoid process to the temporal component ,in which sigmoid notch could not be delineatedType V- ankylosis involving zygomatic arch.

C.JORAM RAVEH ,THIERRY VUILLEMIN CLASSIFICATION1.CLASS I –ankylotic bony tissue limited to the condylar process and articulate fossa.2.CLASS II- the bone mass extends out of the fossa involving the medial aspect of the skull base upto the carotid jugular vessels .3.CLASS III- extension and peneteration into the middle cranial fossa 4.CLASS IV- combination of class 2 and 3.

D.NINTH SHANGHAI CLASSIFICATIONType AI- fibrous ankylosis without bony fusion of the joint Type A2- ankylosis with bony fusion on the lateral side of the joint ,while the residual condyle fragment is bigger than 0.5 of the condylar head in the medial side.Type A3- similar to A2 but the residual condylar fragment is smaller than 0.5 of the condyle head.Type A4- ankylosis with complete bony fusion.

DIAGNOSIS• It depends more upon clinical examination, rather than the diagnostic

test.• Restricted or nil oral opening is seen.• Patient will complain of difficulty in mastication.• Protrusive movements are not possible on the involved side.• Partial mobility or complete immobility of the condyle is readily noticed.• Pain is totally absent• In young patient a nature of facial deformity will help to differentiate b/w

unilateral and bilateral involvement

CLINICAL PRESENTATIONUNILATERAL TMJ ANKYLOSIS• Obvious facial asymmetry• Convex profile• Deviation of the mandible and chin on the affected side• The chin is receded with hypoplastic mandible on the affected side• The appearance of the flatness and elongation on the unaffected

side• The lower border of the mandible on the affected side has a

concavity that ends in a well- defined antegonial notch• In unilateral ankylosis some amount of oral opening may be

possible. Interincial opening will vary depending on whether it is fibrous or bony ankylosis

• Cross bite may be seen• Classic angles malocclusion on the affected side plus unilateral

posterior cross bite on the ipsilateral side seen• Condylar movements are absent on the affected side

BILATERAL TMJ ANKYLOSIS• Inability to open the mouth progresses by gradual

decrease in inter incisal opening. The mandible is symmetrical but micrognathic. The patient develops typical 'bird face' deformity with receding chin.

• The neck chin angle may be reduced or almost completely absent

• Antegonial notch is well defined bilaterally• Class ii malocclusion can be noticed• Upper incisors are often protrusive with anterior

open bite. Maxilla may be narrow• Oral opening will be less than 5mm or many times

there is nil oral opening• Multiple carious teeth with bad periodontal health

can be seen• Severe malocclusion, crowding can be seen and

many impacted teeth may be found on the x-rays.

RADIOLOGIC ASSESSMENT

Clinical examination is the prime method of diagnosing ankylosis though radiological investigation helps in

• Differentiating fibrous ankylosis from bony ankylosis• Degree of involvement of joint• Extra articular involvement of bone• Medial extent of ankylotic mass a.mediolateral width b. relation of the mass to the vital structures medially such as mandibular nerve ,internal carotid artery• Preoperative surgical planning.

The suggested radiologic aids are

1. Orthopantomograph- will show both the joints picture which can be compared in unilateral cases.

2. Lateral oblique view- will give anteroposterior dimension of the condylar mass. Elongation of coronoid process can be seen.

3. Cephalometric radiograph- is taken to evaluate the associated skeletal deformities4. Posteroanterior radiograph- will reveal the medio lateral extent of the bony mass. It will

also highlight the asymmetry in unilateral cases5. CT scan- very helpful guide for surgery. Relation to the medial cranial fossa, the

anteroposterior width, mediolateral depth can be assessed. Any presence of fractured condylar head on the medial aspect of ramus can be located

• FIBROUS ANKYLOSIS- in fibrous ankylosis, reduced joint space and hazy appearance can be seen .But ,still the normal anatomy of the head and glenoid fossa can be appreciated.

• BONY ANKYLOSIS – complete obliteration of joint space .Normal TMJ anatomy is distorted .Deformed condylar head or complete bony consolidation replacing the joint space can be seen .Elongation of the coronoid process on the side of hypomobility will be seen.

SEQUELAE OF UNTREATED ANKYLOSIS• Normal facial growth and development affected.• Speech impairment.• Nutritional impairment.• Respiratory distress, especially in bilateral involvement with severe

micrognathia.• Malocclusion.• Poor oral hygiene.• Multiple carious and impacted teeth

MANAGEMENT

The treatment of TMJ ankylosis is always surgical correction of the ankylosed joint.

Surgical stratergy adopted depends on the following1.Age of onset of ankylosis2.Extent of ankylosis3.Whether it is unilateral or bilateral 4.Associated facial deformity

AIMS AND OBJECTIVE OF SURGERY1.Release of ankylosed mass and creation of a gap to mobilize the joint .2.Creation of a functional joint3.To improve patients nutrition.4.To improve patients oral hygiene 5.To carry out necessary dental treatment.6.To reconstruct the joint and restore the vertical height of the ramus.7.To prevent recurrence.8.To restore normal facial growth pattern9.To improve esthetics.

The Internationally Accepted Protocol For The Management Of Tmj Ankylosis By Kaban, Perrot And Fisher In 1990

Early surgical intervention• Aggressive resection: a gap of atleast 1- 1.5cm should be created. Special attention should be given to

fusion on the medial of the ramus.• Ipsilateral coronoidectomy and tempralis myotomy: in most of these cases there is always

association of elongated coronoid process. After carrying out gap arthoplasty. The coronoidectomy on the same side should be carried out either separately or in combination with the gap arthroplasy cut from the same etraoral incision.

• Lining of the glenoid fossa region with temporalis fascia• Reconstruction of the ramus with a costochondral graft.• Early mobilization and aggressive physiotherapy for the period of at least six months postoperatively• Regular long-term follow-up• To carry to cosmetic Surgery at the later date when the growth of the patient is completed• Release of the jaw movements is quite dramatic, upon competion of coronoid rather than release it

and allow it to be pulled up superior process is removed, there is potential for reankylosis after reattachment.

THREE BASIC METHODS1.Condylectomy2.Gap arthroplasty 3.Interpositional arthroplasty

SURGICAL APPROACHES• Surgical access to the TMJ is an exacting procedure.• TMJ has got close proximity to the main trunk of the facial nerve with its branches in

the temporal and facial areas• It has also got close proximity to the auriculotemporal nerve and the abundant

vascular supplyFollowing approaches are usefull 1.Preauricular2.Post/retro auricular3.Post ramal(HIND approach)4.Endaural approach5.Popwich incision

1.PREAURICULAR APPROACHADVANTAGES

• Inconspicuous location of the incision• Standard approach to the TMJ

DISADVANTAGES• The dissection follows a route through

an area which is rice in nerve and vascular supply.

• BLAIR AND IVY INCISION• THOMA’S ANGULATED INCISION• AL- KAYAT AND BRAMLEY

Blair’s Inverted Hockey Stick

Incision

Thoma’s Angulated Incision

Dingman’s Incision

2.POST/RETRO AURICULAR

ADVANTAGES• Uniform predictability of anatomic

exposure & avoidance of a salivary fistula.• Negligible hemorrage• No distortion of anatomic landmarks

DISADVANTAGES• Infection involving the external auditory

canal• Paresthesis of the external pinna• Small surgical exposure with poor access

and visibility

3.POST RAMAL(HIND) APPROACH

ADVANTAGES• Excellent cosmesis• Excellent visibility and accessibility

DISADVANTAGES• Close proximity of the posterior

facial vein and trunk of the facial nerve

• Proximity of the posterior border of the parotid gland

• Ideal approach to the condyle neck and ramus

4.ENDAURAL APPROACHADVANTAGES

• Excellent cosmetics• Excellent lateral and posterior

exposure with intermediate anterior exposure

DIADVANTAGES• Limited access• Possibility of meatal stenosis

5.POPWICH INCISIONADVANTAGES OF POPWICH’S MODIFICATION• Reduction in incidence of facial nerve palsy• Deceased haemorrhage• Improved visibility • Good cosmetic results• Reduction in total operation time• Avoidance of auriculotemporal nerve

anaesthesia• Reduction in postoperative oedema and

discomfort

SUGICAL PROCEDURES1.CONDYLECTOMY• It is advocated in cases of fibrous ankylosis, where joint

space is obliterted with deposition of fibrous bands , but there is not much deformity of the condylar head.

• Radiologically and clinically after surgical exposure one can see the demarcation between the roof of the glenoid fossa and the head of the condyle.

• The procedure can be done via preauricular incision• The unilateral condylectomy tends to cause devation of the

mandibule towards the operated side on oral opening and if bilateral, anterior open bite will be caused as a result of the loss of the height in the vertical rami.

• Therefore. When the site of the fused joint is mobilized via condylectomy. Then after recontouring by arthroplasty, an alloplastic material can be used to maintain the joint space, satisfactory occlusion and joint movement.

2.GAP ARTHROPLASTY

• In the extensive bony ankylosis, a broad,thick area of bone deposition obliterates the entire joint, sigmoid notch and coronoid process

• Identification of the previous joint structure is impossible and mobilization at level of joint become difficult

• In this operation the level of section is below that previous joint space

• The section consist of two horizontal osteotomy cuts and removal of a bony wedge for creation of a gap between the roof of the glenoid fossa and ramus.

• Minimum gap of 1cm is recommended to pervent reankylosis

3.INTERPOSITIONAL ARTHROPLASTY• It involves the creation of gap , but in addition a barrier is inserted

between the cut bony surfaces to minimize the risk of recurrence and to maintain the vertical height of the ramus

AUTOGENEOUS

1.Cartilaginous graft

Costochondral

Metatarsal

Sternoclavicular

Auricular cartilage

2.Temporalis muscle

3.Temporal fascia

4.Fascia lata

5.Dermis

HETEROGENOUS

1.Chromatized submucosa of pig bladder

2.Lyophilized bovine cartilage(still under research)

ALLOPLAST1. Metallic Tantalum foil /plate 316L stainless steel Titanium Gold2.Nonmetallic Silastic Teflon Acrylic Nylon Proplast Ceramic implants

ARTIFICIAL REPLACEMENT OF JOINT

• Prefabricated condylar prosthesis made of steel ,vitallium or titanium have been also used extensively .

• Fossa liners along with specially constructed TMJ prosthesis reconstruct the entire joint .

• These are commercially available or custom made.

LINING OF THE GLENOID FOSSA SIDE BY TEMPORALIS MYOFAICIAL FLAP

• Tamporalis fascia along with a varying thickness of temporalis muscle may be harvested as an axial flap based on the middle and deep temporal arteries and veins

• The dependable blood supply, the proximity to the tmj and the ability to alter the arc of rotation by basing the flap inferiorly or posteriorly, makes this a versitile flap for lining the glenoid fossa.

• It is used as an interpositional material after release of ankylosis of tmj.

INTERPOSITION ARTHROPLASTY USING AUTOGENOUS COSTOCHONDRAL GRAFT

Basic three goals;1. To replicate structurally normal joint anatomy2. To provide functional articulation3. To establish an area , where adaptive growth can occurs.• Costochondral graft is harvested through the infra-mammary incision• Either 5th, 6th, or 7th rib is harvested.• Costochondral junction of rib is chosen along with some amount of length of the rib.• The length of the total graft will depend on the height of ramus to be restored• Minimum of 1.5cm of costochondral junction should be included in the graft• The graft should be fixed on the lateral aspect of the rammus with the screws.• A minimum gap of 0.5 - 1 cm should be kept between the graft and the glenoid fossa side, so

that free movement is possible without any friction

Disadvantages;• Increased operating time• Additional surgical site• Donor site morbidity• Graft over growth• Possible potential for reankylosis

FALSE ANKYLOSIS• It is a restriction of mandibular movement due to extra articular afflictions.• Miller et al 1975 classified into 6 groups,I. Myogenic causes include fibrosis within muscles possibly due to an organisation

of an intramuscular haematoma.II. Neurogenic group includes central nervous system lesions or cerebrovascular

accidents ,which produce an inhibition of masticatory muscle activity.III. Psychogenic group refers to hysterical trismus .IV. Bone impingement will be caused by extra articular malformations such as

exotosis of the coronoid process ,zygomatic fracture impinging on the mandibular movements.

V. Fibrous scar tissue can form in any soft tissue ,which has been subjected to trauma.

VI. Due to tumours depends upon their site and nature.Treatment Use of mechanical aids from simple acrylic screw wedge to more complicated exercises is beneficial

Acrylic screw wedge

COMPLICATIONS DURING TMJ ANKYLOSIS SURGERY1.DURING ANAESTHESIA

• As the patient cannot open the mouth, awake blind intubation has to be done, where patients cooperation is required, which is very difficult to obtain from younger group of patients

• Because of small mandible and altered position of the larynx .intubation poses a problem

• Aspiration of blood clot tooth or foreign body during extubation as throat cannot be packed prior to surgery

• Danger of falling back of tongue and obstructing airway is always there after extubation

2.DURING SURGERY• Haemorrage due to damage to any of the superficial temporal vessels,

transverse facial artery, inferior alveolar vessel and internal maxillary vessels, pterygoid plexus of veins

• Damage to external auditory meatus• Damage to zygomatic and temporal branch of facial nerve• Damage to glenoid fossa and thus leading entry into middle cranial fossa• Damage to auriculotemporal nerve• Damage to parotid gland• Damage to the teeth during opening of the jaws with jaw stretcher

3.DURING POSTOPERATIVE FOLLOW-UP• Infection• Open bite• Recurrence of ankylosis