BDS 10029 TMJ Surgery Yr 4.pdf

BDS 10029 Temporomandibular Joint Surgery Aims: • The aim of this lecture is to provide an overview of the indications for and management of surgery of the temporomandibular joint. Objectives: On completion of this lecture, the student should be able to: • Understand the indications for surgery of...

BDS 10029 Temporomandibular Joint Surgery Aims: • The aim of this lecture is to provide an overview of the indications for and management of surgery of the temporomandibular joint. Objectives: On completion of this lecture, the student should be able to: • Understand the indications for surgery of the temporomandibular joint • Understand the principle surgical interventions for disease of the temporomandibular joint. Overview • The TMJ is unique for the following reasons:• It’s a Joint that allows both hinge and gliding motions • Both joints are rigidly connected with one another by the mandible, which precludes independent movement. • It is also the only joint whose movement is limited not only by the shape of the articulation, the ligaments, capsule and muscles, • but also the dental occlusion and the contralateral joint. • Temporomandibular joint disorder, also known as TMD, or TMJD, is a general term covering any disorder causing inflammation of the temporomandibular joint • There are a number of conditions that can cause pain in the jaw joint and the muscles involved in the closing and opening of the jaw. • Disorders affecting the temporomandibular joint can affect a person's ability to eat, speak, swallow, chew, and breathe. A person suffering from TMJD may experience: •Clicking or popping noise in the jaw •Being unable to open the mouth comfortably •Locking of the jaw when trying to open the mouth •Neck pain, shoulder pain, back pain or headaches •An irregular bite •Swelling of the face around the jaw joint •Ringing in the ears or decreased hearing TMJ disorders Functional (Myofascial Pain) Pain is diffuse, cyclical Involving muscles of mastication Worse in the morning Structural (Internal Derangement) Localised Pain Exacerbated by jaw motion Mandibular Deviation on Opening and closing • Internal joint derangement can be secondary to a range of pathological conditions including: • dislocation, • displacement/degeneration of the articular disc, • inflammation, infection, trauma or ankylosis of the joint, • condylar hyperplasia, or any neoplastic process (which can be either benign or malignant). • It is important to note that the surgeon should always start treating patients with conservative, reversible procedures aiming to avoid surgery even in internal derangement. • In cases of Myofascial pain , the treatment goals are to alleviate pain, decrease adverse joint loading, • restore mandibular function, reduce or eliminate joint noise, • and allow the patient to return to normal daily activities. ➢ This is done by : ➢ Soft Diet ➢ Hot Packs ➢ Muscle massage ➢ NSAID ➢ Splint therapy to be used overnight This includes night guards and hard acrylic splints • TMJ dysfunction is exacerbated by parafunctional habits • (teeth clenching, grinding, lip biting), occlusal anomalies, • trauma, and stressful life events. • The structural TMJ disorders are treated in a more surgical manner rather than conservative options, ❖ These disorders include Internal derangement of the joint can be secondary to any of the following: ❖ TMJ dislocation, trauma, inflammatory disorders, ❖ meniscal problems, infections, true and false ankylosis, ❖ condylar hyperplasia, and neoplastic disorders The Role of Open Surgery in the Management of TMJ Disorders • Absolute indications for open temporomandibular joint (TMJ) surgery include trauma, congenital deformities, benign and malignant pathology, and end-stage disease, such as ankylosis or condylar resorption. • Relative indications for open TMJ surgery include recurrent mandibular dislocation, arthritis, and disc derangements. Indications for Open surgery Absolute Indications • • • • Trauma Ankylosis Condylar hyperplasia Tumors and Lesions of the Temporomandibular joint Relative Indications • • • • • • • • Recurrent Mandibular Dislocation Disc Derangements of the TMJ Disc Repositioning Disc Repositioning & Discoplasty Disc Repositioning & Arthroplasty Disc Repair Discectomy Disc Replacements • The success of minimally invasive techniques has greatly diminished the role of open surgery for disc derangements. • Internal Derangement is one of the structural TMJ disorders which is characterized by the loss of the relationship between the Disc ( Meniscus) and the condyle. • The disc position is naturally at 12 O’clock position in relationship with the condyle, but due to parafunctional mandibular habits the disc becomes displace to an anteromedial position in relationship to the condyle. • This is due to the insertion of the superior head of the Lateral Pterygoid muscle into the disc, the superactivity of the muscles in cases of bruxism and clenching results in an anterior disc displacement. • This could be reversible with reduction and in an advanced case becomes a closed lock Anterior Disc Displacement with Reduction Anterior Disc Displacement without reduction (Closed lock) Arthrocentesis • The term arthrocentesis means “joint puncture (aspiration),” and the procedure relates to orthopedic experience in the knee joint. • The biological basis of successful TMJ arthrocentesis and lavage has been assessed by outcome studies and synovial fluid analysis. • Flushing out the proinflammatory cytokines, pain mediators, and cartilage matrix degradation products are effective for reduction of pain and disability. Indications • • • • • The primary indication for arthrocentesis is the management of irreducible anterior disc displacement with acute closed lock of the TMJ. It is done under L.A or G.A It is based upon the distention made into the superior joint space by an inlet and outlet needle using Lactated Ringer solution 100-200 mL. At the end of the lavage steroid is injected or Hyaloronate. Immediate postoperative jaw exercise or Physical therapy is mandatory. Surgical Approaches to the TMJ Trauma • TMJ trauma could be managed by Closed or Open and Reduction and internal fixation (ORIF). • This is done to restore function and occlusion Methods of Reduction of TMJ Fractures • Closed Reduction • Using Arch bars & wires ORIF using plates and screws Condylar Hyperplasia • • • • • is a form of growth disturbance , caused by reactivation of the growth center of the affected condyle it results in increased ramal height Open bite Dental deviation • Treatment • Condylectomy • Orthognathic surgery TMJ Ankylosis • TMJ ankylosis is “the pathological fusion between the glenoid fossa of the temporal bone and the condylar process of the mandible.” • It is a severe disability that results in restricted mouth opening, difficulty in mastication, speech, yawning, and nutrition. Etiology • • • • • • • • • • • • • • • • • • 1. Trauma a. Fall on chin leading to indirect injury to TMJ b. Intracapsular or extracapsular fractures of condyle c. Birth trauma—forceps delivery 2. Infections a. Middle ear infection (chronic suppurative otitis media) b. Infected fracture condyle or zygomatic arch c. Osteomyelitis condyle d. Mastoiditis e. Hematogenous infections f. Tuberculosis, syphilis, actinomycosis, and so on 3. Inflammatory pathologies in the joint a. Osteoarthritis b. Ankylosing spondylitis c. Rheumatoid and rheumatic arthritis d. Psoriasis e. SLE 4. Neoplasms: Osteochondroma of condyle Classification • According to location (True and False) • According to type of tissue involved (Bony, Fibrous or fibroosseus) • Extent of Fusion (Complete, Incomplete) True Ankylosis: it involves true adhesions between the articular surfaces. False Ankylosis: are pathological conditions not directly related to the joint but influence it such as: * muscular involvements as Myositis Ossificans • Hysterical trismus • Tetanus • Meningitis • Oral Submucous Fibrosis Facial Features • Deviation of the chin and the mandible toward the side of the defect • Unilateral vertical deficiency of the side of the defect • Retrognathic mandible with a short ramus and small body • Microgenia • Convex facial profile • Bird face deformity: “Andy Gump deformity” • Prominent antegonial notch • Markedly elongated coronoid process • Obstructive sleep apnea in some cases Investigations • Radiographs Orthopantogram PosteroAnterior C.T Scans Chest Xray to examine ribs for costochondral or sternoclavicular graft harvest. Management • • • • • • Goals of Treatment for Temporomandibular Joint Ankylosis Restore mouth opening Restore joint function Allow for condylar growth Correct facial profile Relieve upper airway obstruction Gap Arthroplasty • It is the surgical removal of 1.5cm of the bony ankylotic mass. • This creates a gap to release the ankylosis followed by meticulous physiotherapy . Interpositional Arthroplasty • This involves gap arthroplasty and interposition of an autogenous or alloplastic barrier (6 to 8 mm thick) at the osteotomy site between the two bony ends to help to prevent bony growth and union and thus reduce the risk of recurrence. • This could be done using:• a) Autogenous grafts as Costochondral graft, Sternoclavicular graft, Metatarsal Head, Temporalis Myofascial graft, dermis graft, Fat grafts, Dermal Fat graft, Buccal Fat Pad • b) Interpositional Arthroplasty with an Autogenous or Alloplastic barrier (6 – 8 mm thick) at the osteotomy site between the two bony ends to help to prevent growth and reankylosis. • Many materials can be used such as Temporalis muscle fascia, auricular cartilage, fascia lata, dermal fat, lyophilised cartilage, and dura. Recurrent Mandibular Dislocation • is a condition when the condyle is displaced beyond the articular eminence. • It could be unilateral or bilateral. • CLINICAL PRESENTATION • Signs and symptoms are the same for acute and chronic dislocation • Inability to close mouth • Severe pain over TMJ • Preauricular skin depression, which is palpable • Excessive salivation • Tense, spasm of the masticatory muscles Precipitating factors to Mandibular dislocation • Blows or trauma to mandible (especially if mouth open) • Wide opening during singing, yawning • Protracted dental procedures: Use of bite blocks can help prevent • General anesthetic/intubation/endoscopy procedures • Medications: Especially psychiatric and those producing extrapyramidal side effects • Neurological dysfunction: Cerebral palsy, epilepsy • Psychiatric disorders • Systemic conditions: Ehlers-Danlos syndrome, rheumatoid arthritis • Ligamentous laxity • Hypermobility disorder • Altered occlusion: Deep overbite, edentulous patients Etiology • Abnormal Shape Glenoid Fossa/Condylar Head. • Loss of Dentition Leading to Overclosure and Joint Laxity • Laxity of the Temporomandibular Joint Ligaments/Capsule • Hyperfunction of the Temporomandibular Joint Musculature Types of Dislocation Acute Recurrent Chronic Management • The emergency management of acute dislocation includes the reduction of the mandible. • It requires inferior disimpaction of posterior mandible to overcome articular eminence obstruction and muscle spasm, allowing posterior repositioning of condylar heads. Management of Recurrent dislocation • Muscle Modification • Ligament Modification this is done to limit the anterior condylar movement beyond the • Bone Modification articular eminence Management of Recurrent dislocation • Patients with recurrent TMJ dislocation should have a period of noninvasive management, including education • regarding avoidance of precipitating events and methods of self-reduction, • physiotherapy. Management of Recurrent dislocation • In chronic TMJ dislocation (duration greater than 1month), if reduction is not possible then osteotomy may be considered to restore a nonfunctioning occlusion. y be • If there is no movement of the condyle in its chronically displaced position, then coronoidotomy, condylotomy, condylectomy, • or even prosthetic replacement may be necessary. Take Home Message • TMJ dysfunction is the most common non infective pain • disorder of the orofacial region. • The treatment of TMJ disorders almost always should be • nonsurgical in nature, in the first instance. • TMJ dysfunction is exacerbated by parafunctional habits • (teeth clenching, grinding, lip biting), occlusal anomalies, • trauma, and stressful life events. Aims: • The aim of this lecture is to provide an overview of the indications for and management of surgery of the temporomandibular joint. Objectives: On completion of this lecture, the student should be able to: • Understand the indications for surgery of the temporomandibular joint • Understand the principle surgical interventions for disease of the temporomandibular joint. Further reading 1. Kerawala C, Newlands C. Oral and Maxillofacial Surgery. Oxford University Press, 2010 pp 346-347 2. Brennan et al. Maxillofacial Surgery Volume 3. Elsevier 2017 pp 1465-1523