Temporomandibular Disorders - LIAQUAT University Medical & Health Sciences - 2016 PDF

LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES 2nd International LUMHS Dental Conference, 28th Oct; 2016  TEMPOROMANDIB ULAR DISORDERS ORAL MEDICINE DEPARTMENT FACULTY OF DENTISTRY LUMHS, Jamshoro ITEM 11 (SYALLBUS)  Temporomandibular Joint Pain Dysfunction and Disorders Descrip...

LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES 2nd International LUMHS Dental Conference, 28th Oct; 2016  TEMPOROMANDIB ULAR DISORDERS ORAL MEDICINE DEPARTMENT FACULTY OF DENTISTRY LUMHS, Jamshoro ITEM 11 (SYALLBUS)  Temporomandibular Joint Pain Dysfunction and Disorders Description:  TMJ Pain Dysfunction Syndrome, Possible Etiological Factors and Pathogenesis, Management long and short term, Disc and Joint Injuries, Bacterial infections and related diseases Pathogenesis and Management LEARNING OUTCOME At the end of this presentation students will be able to:  Define the TMJ  Classify the diseases of TMJ  Assessment of TMJ  General management of TMJ Disorders  TEMPOROMANDIBULAR JOINT  A bilateral synovial joint formed by the articulation of the temporal bone of the cranium and the mandibular condyle.  TEMPOROMANDIBULAR DISORDERS: term embracing a number of problems involving the masticatory muscles, the temporomandibular joints and associated structures. FUNCTIONAL ANATOMY TEMPOROMANDIBULAR JOINT  Hinge type and gliding movements  S-shaped form of the fossa and eminence develops at about 6 years of age and continues into the second decade.  Rotation of the condyle contributes more to normal mouth opening than translation.  Weeping lubrication (Synovial Fluid)  Boundary lubrication  Covering of fibrocartilage on the articulating surfaces.  ARTICULAR DISC  A fibrocartilage disc made up of dense collagen fibres and occupies the space between the fibrocartilage coverings of the condyle and the mandibular fossa.  It is primarily avascular and has little sensory nerve innervation.  It is attached by ligaments to the medial and lateral aspects of the condyle.  The normal disc is thinnest in the intermediate zone and thickens to form anterior and posterior bands.  Fibres of the posterior 1/3 of the temporalis and of the deep masseter and fibres of the lateral pterygoid insert into the anterolateral aspect and anteromedial 2/3 of the disc. RETRODISCAL TISSUE  Mass of soft tissue occupying the space behind the disc and the condyle and is referred to as the posterior attachment.  Superior lamina- posterior band of the disc to the squamotympanic fissure and the tympanic part of the temporal bone.  Inferior lamina- posterior band of the disc to the inferior margin of the posterior slope of the condyle TEMPOROMANDIBULAR LIGAMENTS  CAPSULAR LIGAMENT  LATERAL TEMPOROMANDIBULAR LIGAMENT  SPHENOMANDIBULAR LIGAMENT  STYLOMANDIBULAR LIGAMENT MUSCLES OF MASTICATION  Mandibular movements toward the tooth contact position are performed by the contraction of the masseter, temporalis and the medial pterygoid muscles.  Masseter and medial pterygoid form a sling that produces the powerful forces required for chewing.  Masseter is the most superficial and most obvious muscle, consisting of superficial and deep heads and elevates the mandible.   MASSETER:  TEMPORALIS:  Superficial head: arises by a  Anterior, middle and thick, tendinous aponeurosis from posterior parts the temporal process of zygomatic  Inserts on the bone, and from the anterior two- thirds of the inferior border of coronoid process the zygomatic arch and inserts into and anterior aspect the angle of the mandible and of the mandibular inferior half of the lateral surface of ramus. the ramus of the mandible.  Deep head: arises from the posterior third of the lower border and from the whole of the medial surface of the zygomatic arch and inserts into the upper half of the ramus.  MEDIAL PTERYGOID:  LATERAL PTERYGOID:  It consists of two heads, the bulk of  Main protrusive and opening muscle the muscle arises as a deep head of the mandible. from just above the medial surface  Inferior head originates from the of the lateral pterygoid plate while outer surface of the lateral pterygoid the smaller, superficial head plate and the pyramidal processes of the palatine bones. originates from the maxillary tuberosity and the pyramidal  Superior head originates from the process of the palatine bone. greater wing of the sphenoid and the pterygoid ridge. They both insert  Inserts into the lower and back part into the anteriomedial aspect of the of the medial surface of condylar neck. the ramus and angle of  Superior head is active during the mandible, as high as closing movements. the mandibular foramen.  Inferior head is responsible for the  Excursion of the mandible; lateral movements when teeth are in contralateral excursion occurs with contact. unilateral contraction.  Contraction of the anterior belly of diagastric produces depression and the retropositioning of the mandible.  Mylohyoid and geniohyoid also contribute to depressing and retrusion of the mandible.  Buccinator helps positioning the cheek during chewing movements. VASCULAR SUPPLY OF MASTICATORY SYSTEM STRUCTURES  External carotid artery  Bifurcates at the level of condyle into the superficial temporal and internal maxillary artery which supplies the muscles of mastication and the TMJ. NERVE SUPPLY OF MASTICATORY SYSTEM STRUCTURES  Mandibular division of the trigeminal nerve supplies motor innervation to the muscles of mastication and the anterior belly of diagastric.  Auriculotemporal nerve (MN) supplies the sensory innervation to the TMJ.  The deep temporal and masseteric nerve supplies the anterior portion of the joint. ANATOMY OF CLINICAL INTEREST  JAW JERK REFLEX: Monosynaptic reflex contraction of the jaw closing muscles.  JAW OPENING REFLEX: Polysynaptic reflex resulting in the inhibition of the jaw closing muscles.  REST POSITION  CENTRIC RELATION: The maxillomandibular relationship in which each condyle articulates with the thinnest avascular portion of the disc in an anteriosuperior position against the posterior slope of the articular eminence.  MANDIBULAR RANGE OF MOTION: The average rotation of the condyle is calculated to be 24˚ and the condylar translation to extend 13-15 mm before achieving maximum opening (40-45 mm).  ARTICULAR COVERING: It is thickest at the areas of greatest functional load.  DISC DISPLACEMENTS: Injury to the inferior lamina of the posterior attachment is thought of as the cause of disc displacement.  The angle or steepness of the mandibular fossa has been considered a contributing factor in the development or aggravation of intra articular disorders and in chronic subluxation or dislocation of the condyle.  Adhesion of the disc in the fossa might cause acute closed lock.  MUSCLE PALPATION: The most widely used clinical test for the assessment of TMD.  JAW JERK REFLEX AND THE SILENT PERIOD: Electromyographic (EMG) activity  JOINT NOISES: TMJ clicking might be due to ADD, condylar hypermobility, enlargement of the lateral pole of the condyle, structural irregularity of the articular eminence, loose intra-articular bodies, and dysfunctional movement patterns or inco-ordination.   NERVE ENTRAPMENT  EAR SYMPTOMS ASSOCIATED WITH TMDs: Ear ache, tinnitus, and fullness or a feeling of stiffness. LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES 2nd International LUMHS Dental Conference, 28th Oct; 2016 TEMPOROMANDIB ULAR DISORDERS ETIOLOGY, EPIDEMIOLOGY, AND CLASSIFICATION  ETIOLOGY:  Premature occlusal contacts  Masticatory muscle hyperactivity- sleep bruxism and awaking parafunction  Parafunctional behaviors  Psychological distress  Trauma  Rheumatic disorders  EPIDEMIOLOGY:  TMDs are most prevalent between the ages of 20 and 40 years and twice as common in women as in men. CLASSIFICATION ASSESSMENT  HISTORY  The most common symptom related to TMD is pain. Other complains include restricted jaw movement, painful or loud TMJ clicking or crepitus, and jaw locking.  BEHAVIORAL ASSESSMENT  Important to better understand the reported pain and not assume as if an underlying physical pathology is responsible, anticipate barriers in achieving successful results, and the potential for relapse.  Dysfunctional, interpersonally distressed and adaptive copers.  Indicators for expert psychological evaluation: i. Persistence of pain ii. Poor response iii. Significant distress iv. Greater disability v. Inappropriate use of services vi. Excessive reliance PHYSICAL EXAMINATION  Masticatory muscle tenderness on palpation is the most consistent examination feature present in TMDs. 1. MANDIBULAR RANGE OF MOTION: comprises three procedures in the vertical and horizontal planes.  Three vertical procedures include pain free opening, maximal unassisted opening, and maximal assisted opening.  Three horizontal procedures include right, left lateral, and protrusive movements of the mandible. 2. TMJ NOISES: TMJ clicking or crepitus 3. PALPATION FOR PAIN: Level of pain replication  Parameters affecting palpation as a procedure include amount of loading to the tissue, surface area of loading, and where the loading is applied.  Duration of loading vs pressure on loading  Where to palpate?  Severity of the pain provoked. 4. PROVOCATION TESTS: Designed to elicit the pain of complaint. Four types of functional tests have been recommended.  Static muscle contraction test  Dynamic muscle contraction test  Bilateral loading via clench  Unilateral loading via clench 5. ASSESSMENT OF CONSEQUENCES OF PARAFUNCTIONAL BEHAVIORS:  Tooth wear, soft tissue changes (lip or cheek chewing, an accentuated occlusal line, scalloped tongue borders, and hypertrophic jaw closing muscles. 6. CERVICAL REGION-ROM AND PALPATION OF MUSCLES:  The cervical area and masticatory area have several linkages:  mechanical, motor control, and afferent.  Mobility  Palpation DIAGNOSTIC IMAGING  Plain film radiography  Plain film tomography  Arthrography  CT scan  MRI  Single photon emission CT  Radioisotope scanning DIAGNOSTIC LOCAL ANESTHETIC NERVE BLOCKS  Injections into the TMJ, selected masticatory muscles, or trigger areas PREDICTION OF CHRONICITY Defined as  pain that extends beyond a certain period  Pain that persists beyond the time of usual healing  Pain that does not respond to usual treatment. GENERAL PRINCIPLES OF TREATING TEMPOROMANDIBULAR DISORDERS  Treatment goals for TMD  Patient are allocated roughly into three categories:  Remission,  Recurring symptoms,  Persisting symptoms  Surgical intervention  Relaxation and cognitive-behavioral therapies (CBT)  When to refer? LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES 2nd International LUMHS Dental Conference, 28th Oct; 2016 TEMPOROMANDIB ULAR DISORDERS SPECIFIC DISORDERS AND THEIR MANAGEMENT MYALGIA AND MYOFASCIAL PAIN OF THE MASTICATORY MUSCLES  Local myalgia and Myofascial pain  Education and information  Self management: muscle stretching, use of thermal agents, avoidance of strain or overuse while chewing.  Parafunctional behavior control  Physiotherapy: active and passive modalities (ultrasound, cold laser, and transcutaneous electrical nerve stimulation)  Intra oral appliances: splints, orthotics, orthopaedic appliances, night guards, bite guards  Pharmacotherapy: NSAIDs, acetaminophen, muscle relaxants, anxiolytics, tricyclic anti-depressants.  Behavioral therapy: relaxation techniques (autogenic training, meditation, progressive muscle relaxation), biofeedback, hypnosis, CBT  Trigger point therapy: spray and stretch therapy, injection of local anesthetic  Restorative dental procedures in TMD patients INTRA ORAL APPLIANCES ARTICULAR DISC DISORDERS OF THE TMJ  An abnormal relationship between the disc, the mandibular condyle, and the articular eminence, resulting from the elongation or tearing of the attachment of the disc to the condyle and glenoid fossa.  Most common disc displacement is anterior and medial to the condyle.  Divided into stages based on the signs and symptoms combined with results of diagnostic imaging.  ADD with reduction  ADD with intermittent locking  ADD without reduction  ANTERIOR DISC DISPLACEMENT WITH REDUCTION  An articular disc that has been displaced from its position on top of the condyle.  Clicking and popping sounds during all mandibular movements.  Repositioning and restabilization splints.  ANTERIOR DISC DISPLACEMENT WITHOUT REDUCTION  Often referred to as closed lock  Pain over the locked joint, limited lateral movement to the side away from the affected joint, deviation of the mandible during opening.  Goals of successful treatment are to eliminate pain, restore function, and increase the range of mandibular motion.  Occlusal stabilization appliance, medications, arthrocentesis, arthroscopy. POSTERIOR DISC DISPLACEMENT  Condyle slipping over the anterior rim of the disc and it being caught and brought backward.  Prevents full mouth closure  Sudden inability to achieve maximal occlusion  Pain in the affected joint  Forward displacement of the mandible  Restricted lateral movement  No restriction of mouth opening  TEMPOROMANDIBULAR JOINT ARTHRITIS  DEGENERATIVE JOINT DISEASES:  A disorder of articular cartilage and subchondral bone, with secondary inflammation of the synovial membrane.  Can be categorized as primary or secondary  Risk factors include gender, diet, genetics and psychological stress.  Pain over the condyle, limitation of opening, crepitus, stiffness after inactivity  Narrowing of the joint space, , irregular joint space, flattening of the articular surfaces, osteophyte formation, anterior lipping of condyle, subchondral cysts.  RHEUMATOID ARTHRITIS:  Primarily affects periarticular tissue and secondarily bone  Involved bilaterally  Morning stiffness, joint sounds, tenderness and swelling in the area. SYNOVIAL CHONDROMATOSIS  Uncommon benign disorder characterized by synovial metaplasia and presence of multiple cartilaginous nodules of synovial membrane that free float in the joint.  Slow, progressive swelling in the preauricular region, pain, and limitation of mandibular movement.  TMJ clicking, locking, crepitus, and occlusal changes may also be present.  Conventional radiography, arthroscopy, CT scan  Arthroscopic removal, arthrotomy SEPTIC ARTHRITIS  Previously existing joint disease, diabetes, immunosuppressive drugs, long term corticosteroid use, infections.  Gonococci, Staphylococcus aureus  Trismus, deviation of the mandible, severe pain on movement, inability to occlude.  Redness and swelling, large, tender cervical lymph nodes  Culture  Osteomyelitis of the temporal bone, brain abscess, and ankylosis.  Surgical drainage, joint irrigation, antibiotics DEVELOPMENTAL DISTURBANCES  Condylar hyperplasia  Condylar hypoplasia  Agenesis of the condyle FRACTURES  Often results from blow to the chin  Pain and edema over the joint area and limitation and deviation on opening to the injured site.  Open bite in cases of bilateral condylar fractures. DISLOCATION  Condyle is positioned anterior to the articular eminence and cannot return to its normal position without assistance.  Inability to close the jaws and pain due to muscle spasms  Repositioning  Chronic recurring dislocations: bone grafting to the eminence, lateral pterygoid myotomy, eminence reduction, eminence augmentation, shortening the temporalis tendon, plication of the joint capsule, repositioning of the zygomatic arch. ANKYLOSIS  Fusion of the head of the condyle to the temporal bone  Limited mandibular movement, deviation of the mandible to the affected side on opening, and facial asymmetry.  Gap arthroplasty using interpositional materials between cuts SLEEP BRUXISM  Oral appliance therapy  Selective serotonin uptake inhibitors  Botulinum toxin ORAL DYSKINESIA AND DYSTONIA  Abnormal, involuntary movements of the tongue, lips and jaw.  Complete loss of teeth, ill fitting dentures, lack of replacement.  Emphasis is on management.  Oromandibular dystonia produces involuntary and excessive contractions of tongue, lip and jaw muscles.  Botulinum toxin and neurosurgical intervention THANK YOU !!