BONY BONY ANATOMYANATOMY

Saggital aspectSaggital aspect

coronal aspectcoronal aspect

Glenoid fossa & articular eminenceGlenoid fossa & articular eminence

TMJ CORONAL VIEWTMJ CORONAL VIEW

ARTICULAR CARTILAGEARTICULAR CARTILAGE

TMJ LATERAL VIEWTMJ LATERAL VIEW

SOFT TISSUE ANATOMY

TMJ capsuleTMJ ligamentsDisc(meniscus)Synovial membrane

TMJ LIGAMENTSTMJ LIGAMENTS

CAPSULAR LIGAMENT CAPSULAR LIGAMENT (LATERAL VIEW)(LATERAL VIEW)

TMJ WITH TMJ WITH MUSCLE MUSCLE ATTACHMENTATTACHMENT

TEMPORALIS MUSCLE TEMPORALIS MUSCLE (WITH ZYGOMATIC ARCH & MASSETER MUSCLE REMOVED)(WITH ZYGOMATIC ARCH & MASSETER MUSCLE REMOVED)

MASSETER MUSCLEMASSETER MUSCLE

LATERAL & MEDIAL PTERYGOIDLATERAL & MEDIAL PTERYGOID

Blood supply- Branches from Superficial temporal & Maxillary Artery

Nerve supply- Auriculotemporal & Masseteric Nerve

TMJ PATHOLOGY – PT’S HISTORYTMJ PATHOLOGY – PT’S HISTORY

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

Oral habit : Bruxism Chewing pattern

Medical history : Rheumatoid arthritis Extraction Trauma H/O : Headache Back pain Ear ache

Family history : Rheumatoid arthritis Osteoarthritis

CLINICAL EXAMINATION

Facial symmetry Mouth opening TMJ palpation Muscle palpation Dental examination

MYOFASCIAL PAIN DYSFUNCTION SYNDROME

or MASTICATORY MYALGIA

orCOSTEIN’S SYNDROME

orTMJ ARTHROSIS

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.

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)

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

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 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

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 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.

( MRI )

Adv. - Doesn’t use ionising radiation. non invasive excellent for soft tissue

Disadv. - very expensive patient discomfort

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 :

With reduction. Without reduction

1. Anterior disc displacement.

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 / 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.

Aetiology:

Primary

secondary

Unknown but role of genetic. – chronic microtrauma - metabolic disease

• clinical feature:clinical feature: Symptomatic AsymptomaticSymptomatic Asymptomatic

Unilateral pain over condyleUnilateral pain over condyleLimitation of mouth openingLimitation of mouth openingCrepitusCrepitusFeeling of stiffnessFeeling of stiffness

• 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)

Treatment:Treatment:

Conservative surgery -NSAIDs -arthroplasty(removal of

osteophyte -soft diet & erosion area of bone) -intra articular steroid -high condylectomy-

occlusal splint -replacment

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.

EtiologyEtiology

Intrinsic trauma Extrinsic trauma

Yawn Blow to mandibleVomiting During intubation in GA.Singing Dental extractionLaughingSeizure

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

2. Bilateral involvement

Pain(due to spasm)Hollow in front tragus in bilateral siteLateral pole of condyle is prominentOpen bite Protruding chinDifficulty in speech

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.

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

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

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

False ankylosis:

muscular trismusmuscular fibrosismyositis ossificanstetanytetanusneurogenic causedrug indused# of zygomatic archbands of scar tissues

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

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.

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

Surgical approach to TMJ:

Pre auricular Post auricularEnd auralTemporal Trans coronal or question mark approachsubmandibular incision

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.

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

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