Temporomandibular Joint Disorders - PowerPoint Presentation PDF

Temporomandibular Joint Disorders II Dr. Wael M. Talaat Associate Professor of Oral & Maxillofacial Surgery University of Sharjah  Objectives 1) Awareness of the diagnosis and treatment of Arthritis of the TMJ. 2) Knowledge of the...

Temporomandibular Joint Disorders II Dr. Wael M. Talaat Associate Professor of Oral & Maxillofacial Surgery University of Sharjah  Objectives 1) Awareness of the diagnosis and treatment of Arthritis of the TMJ. 2) Knowledge of the classification, diagnosis and treatment of Ankylosis of the TMJ. 3) Understanding Sublaxation and Dislocation of the TMJ. Arthritis  Classification Degenerative joint disorder/osteoarthritis Systemic arthritic condition: rheumatoid arthritis  Degenerative arthritis Causes: aging ,trauma and secondary from other joint disease Clinically: pain associated with crepitus, obvious limitation of opening Symptoms usually increase with function Variety of anatomical findings: -- Disk :irregular , perforated , severely damaged -- Articular surface: flattening , erosions, osteophyte formation, subcortical cysts Arthritis  Rheumatoid arthritis Non organ specific autoimmune systemic disorder. Involve Multiple joints of the body. Inflammation of the synovial membranes. In severe cases osseous tissues are resorbed. Commonly associated with the joints of hands and wrist.  Rheumatoid arthritis Clinical Features : Incidence higher in females, increases with age. Small joints of hand, wrist, feet, knees, affected in bilateral symmetric fashion. TMJ involvement: swelling, pain, tenderness, stiffness on opening mouth, limited range of motion and crepitus.  Rheumatoid arthritis Radiographic features: Generalized osteopenia (bone mineral density is lower than normal ) of condyle & temporal bone component. Erosion of the condylar surfaces.  Rheumatoid arthritis In end stage rheumatoid arthritis the joint space obliteration results in destruction of anterior and posterior aspect of condylar heads. In juvenile rheumatoid arthritis with TMJ involvement, end stage disease can result in destruction of the condylar growth plate. May Also lead to................ ??? Ankylosis ANKYLOSIS: Inability to open the mouth beyond 5mm of inter-incisal opening. Ankylosis, or Anchylosis ( from Greek αγκυλος, bent, crooked ) -When the structures outside the joint are involved, it is termed "false ankylosis”. - in contrast when the disease involves the TMJ itself, it is called "true ankylosis”. - When inflammation causes the joint-ends of the bones to be fused together the ankylosis is termed “ osseous” or complete. CLASSIFICATION OF ANKYLOSIS: 1. False ankylosis or true ankylosis. 2. Extra - articular or intra - articular. 3. Fibrous or bony. 4. Unilateral or bilateral. 5. Partial or complete. ETIOPATHOLOGY OF THE ANKYLOSIS OF TMJ FALSE ANKYLOSIS CAUSES: 1. MUSCULAR TRISMUS It can be established because of pericoronitis, infection adjoining the muscles of mastication involving submasseteric, pterygomandibular, infratemporal or submandibular spaces. 2. MUSCULAR FIBROSIS from any long standing dysfunction like arthritis and myositis. 3. MYOSITIS OSSIFICANS When there is progressive ossification after injury and hematoma formation especially of the masseter muscle, inability to open the mouth develops. This can be confirmed radiologically as well. 4. TETANY When there is hypocalcaemia, the spasms in the muscles are produced hampering the opening of the mouth. 5. TETANUS Acute infectious disease caused by Clostridium tetani is represented by an early symptom of lock-jaw because of persistent tonic spasm of the muscles. 6. NEUROGENIC CAUSES Like epilepsy, brain tumour and embolic hemorrhage in medulla oblongata are also represented by hypomobility of the jaw. 7. TRISMUS HYSTERICUS It is a disease of psychogenic origin. 8. DRUG INDUCED SPASMS Drug induced spasms like in drug poisoning. 9. MECHANICAL BLOCKADE on account of osteoma or elongation of the coronoid process of the mandible. 10. FRACTURE OF THE ZYGOMATIC ARCH Fracture of the zygomatic arch with inward buckling. 11. FRACTURE OF THE MANDIBLE Reflex spasm of the muscles and hence trismus. 12. SCARS AND BURNS OF THE FACE 13. CLEFT PALATE OPERATIONS can produce fibrosis of the pterygomandibular raphe and, consequently, limitation of mouth opening. 14. SUBMUCOUS FIBROSIS Submucous fibrosis results in tense fibrous bands in the cheeks which stretch from mandible to maxilla limiting movement of the mandible, tongue and soft palate.  TRUE ANKYLOSIS True ankylosis, is a condition that produces - fibrous adhesions or - bony union between the articulating surfaces of TMJ and may be classified as: - Fibrous, - Fibro - osseous and - Bony ankylosis. Further, it may be unilateral or bilateral and partial or complete.  Etiopathology 1. Birth Trauma Birth trauma producing so-called congenital ankylosis and occurs in cases of difficult delivery, particularly forceps delivery. 2. Haemarthrosis Due to: - fracture of the base of skull extending through the mandibular fossa or an intracapsular injury. The hematoma within the joint organises slowly which is then converted to fibrous tissue and then bone resulting in bony ankylosis.  3. Suppurative arthritis may be due to infection of the ear or mastoiditis or it may be of hematogenous origin leading to ankylosis. 4. Rheumatoid arthritis There is associated atrophy of the muscles generally accompanying ankylosis, if contracted early in life. 5. Osteomyelitis Osteomyelitis affecting the mandibular condyle frequently results in limitation of motion + peri-articular swelling, and suppuration often results in fistula formation. 6. Fracture of the condyle especially comminuted fractures Trauma to the condyle in children is more likely to cause ankylosis than adults.  This is because condylar structure of children is different than adults. In a child the neck of the condyle is short & stubby but in adults its longer & narrower. Due to this, trauma in an adult is likely to fracture the condylar neck but in a child it is likely to cause intra-capsular fracture CLINICAL FEATURES  CLINICAL FEATURES: 1. Early joint involvement - less than 15 years: Severe facial deformity and loss of function. 2. Later joint involvement after the age of 15 years: Facial deformity marginal or nil. But, functional loss severe. Those patients in whom the ankylosis develops after full growth completion have no facial deformity.  Pain is not an outstanding symptom, it is present only in the early stages of the disease. On inspection see: Healed chin laceration Reduced interincisal mouth opening or NO mouth opening at all + neglected oral hygiene + impacted / malposed /carious teeth. Inability to masticate food.  In cases in which the disease was contracted early in life, a so-called ‘bird face’ results. This includes - a receding chin, - malocclusion,and - impaction of teeth. The maxilla may be narrow and protrude  There is underdevelopment of the mandible associated with a prominent angle of the jaw and curve of the inferior border called ‘ante - gonial notching’. This ante-gonial notching or curve denotes an attempt at bending the bone by the powerful depressor muscles, which come into function when great force is needed to open the jaw  In BILATERAL ANKYLOSIS you will observe the following: 1. Bird face deformity + micro gnathic mandible 2. Class II malocclusion 3. Deep ante - gonial notching 4. Severe malocclusion with crowding + protrusive upper anterior teeth + anterior open bite  In UNILATERAL ANKYLOSIS you will find : 1. Facial asymmetry with affected side appearing normal & the opposite side appearing flat. 2. Chin is deviated to the ankylosed side. This is because the normal side continues to grow & pushes the mandible to the affected side giving appearance of fullness on the ankylosed side. 3. Ante-gonial notch on the affected side 4. Minimal condylar movements on palpation. 5. Class II malocclusion on affected side and cross bite may be seen If the disease is contracted early in life, There is destruction of the growth center [situated in the condyle] with absence of functional stimulation preventing the normal development of the jaw This, in turn prevents normal eruption of the teeth and causes micrognathia  Diagnosis Diagnosis is based on: 1. History of infection or trauma 2. Findings at clinical examination (reduced interincisal opening + diminished/no TMJ movements + scar on the chin due to trauma) 3. Radiological findings  CT Scan/3D CT Scan 3D CT SCAN showing Bony Ankylosis Coronal CT Scan showing TMJ Ankylosis CONE BEAM 3D CT SCAN  What happens if Ankylosis is left untreated ? 1. Normal growth & development of face is affected 2. There is Nutritional impairment 3. Speech impairment 4. Sleep apnea ( tongue falls back in sleep) in Bilateral Ankylosis. 5. Malocclusion 6. Poor and neglected oral hygiene 7. Multiple carious and impacted teeth.  KABAN’S PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS 1. Early surgical management 2. Aggressive total excision of the ankylotic mass 3. Coronoidectomy + myotomy on the affected side to eliminate temporalis muscle restriction. 4. Lining with temporalis muscle/fascia 5. If steps 1 + 2 + 3 do not create enough opening, opposite side coronoidectomy is done. 6. Reconstruction of ramal height with costochondral graft 7. Early post-operative mobilisation and aggressive physiotherapy for at least 6 -12 months 8. Orthognathic surgery to be carried out as a secondary procedure, when growth has completed SURGICAL PROCEDURES TIMING OF SURGERY Surgery for Ankylosis can be done in 2 stages: In the first stage surgery, only release of ankylosis with costochondral graft in young patients is done to bring about jaw mobility and growth. In the second stage surgery an orthognathic surgery can be planned to restore facial esthetics. Some surgeons prefer to use a single stage procedure where release of ankylosis and esthetic correction are done in a single stage in adults or after cessation of growth spurts in children. Left: Preauricular Incision showing surgical exposure and the Ankylotic bony mass Right: Surgical exposure showing the condyle fused to the zygomatic arch forming ankylotic mass Left: Ostoetomy Cut Right: After the osteotomy, a gap of at least 1.5 – 2 cms between the roof of the fossa and the mandible is made. Costochondral Graft can be fixed with either miniplates or lag screws Hypermobility: TMJ Dislocation  TMJ Dislocation A long-lasting inability to close the mouth. It is often associated with an abnormally wide opening while eating or yawning. A condylar position anterior and superior to the articular eminence that is not self- reducing. It is observed most frequently in patients with neurologic and connective tissue disorders, those with TMJ dysfunction.  Extrinsic trauma, especially that sustained while the mouth is open, may result in dislocation. Patients generally present with associated muscle spasm and pain.  Treatment Reduction of mandibular dislocation should be done before muscle spasm becomes severe and makes the procedure more difficult. Reduction is accomplished by pressing the mandible downward and then backward to relocate the condyle within the glenoid fossa  Bimanual mandibular manipulation in a downward-posterior direction to disengage the condyle from its open-locked position posterior to the articular eminence.  In acute cases this can generally be accomplished without the use of anesthesia. In cases of prolonged or chronic dislocation, the use of muscle relaxants and analgesics may be required. If reduction cannot be thus achieved, general anesthesia may be required.  After reduction the mandible should be immobilized for several days to allow for capsular repair, muscle rest, and prevention of recurrence. Mechanical impediments to condylar translation effectively deepen the glenoid fossa. Bone and cartilage grafts (cranial, iliac crest, rib, tibial) have been used for this purpose. Non autogenous material has also been onlayed to the articular eminence.  Open eminectomy (can be done via the arthroscope) involve the removal of a portion of the articular eminence to allow the condyle to move freely. Hypermobility: Mandibular Subluxation Mandibular Subluxation A momentary inability to close the mouth from a maximally open position. Defined as a self-reducing partial dislocation of the TMJ, during which the condyle passes anterior to the articular eminence.  Extended periods of mouth opening (eg, during dental treatment or endotracheal anesthesia) may precipitate subluxation. Subluxation may occur secondary to acute trauma or following a seizure and Parkinson’s disease.  Treatment In the absence of pain, subluxation requires no specific treatment since it is self-reduced by the patient. When associated with wide mouth opening, conscious efforts to avoid this are usually successful at preventing recurrent subluxation. Prolotherapy is a minimally invasive approach by injecting a sclerosing agent.  Patients are advised to modify their diets, and dental treatment is done over multiple shorter appointments. The use of bite blocks during procedures can also be helpful. In cases in which extreme laxity in the joint results in continued problems, surgical intervention may be warranted. Thank You