TEMPOROMANDIBULAR DISORDERS

PRESENTED BY: Dr. MADAAN

ANATOMY OF TMJ
Definition: It is a synovial joint of bicondylar variety. (CRANIOMANDIBULAR ARTICULATION) Also called the GINGLYMODIARTHRODIAL JOINT. Articular surfaces : 2 articular surfaces

upper Roof: 2 parts of temporal bone Floor: superior surface of disc Articular eminence Roof: inferior surface of disc lower

Anterior part of mandibular fossa

Floor: Articulating surface of the mandibular condyle

ARTICULAR DISC
It is an oval fibrous plate that divides the joint into an upper & lower compartment. Also referred to as FIBROCARTILAGE Concavo-convex superior surface and a concave inferior surface.

LIGAMENTS

FIBROUS CAPSULE: Attached above to the articular eminence & the squamotympanic fissure below to the neck of the condyle.

LATERAL LIGAMENT: (temporo mandibular ligament) Fibers are directed backwards and downwards. Attached above to the articular tubercle & below to the posterolateral aspect of the neck of the mandible.

SPHENO MANDIBULAR LIGAMENT: Attached to supine of Sphenoid & inferior to the lingula of the mandible

STYLO MANDIBULAR LIGAMENT: Attached above to the Lateral surface Of the styloid process & below to the angle & posterior border of ramus of the mandible

BLOOD SUPPLY

NERVE SUPPLY

MOVEMENTS: PROTRACTION OF MANDIBLE: The articular disc glides forwards over the upper articular surface, the head of the mandible moving with it. RETRACTION OF MANDIBLE : Reversal of protraction SLIGHT OPENING OF THE MOUTH: The head of the mandible moves on the undersurface of the disc like a hinge.

WIDE OPENING OF THE MOUTH : Hinge like movement followed by gliding of the disc & head of mandible.
LATERAL MOVEMENTS: Head of one side glides forwards along with disc but head of the opposite side merely rotates on vertical axis.

BORDER MOVEMENTS Maximum movement of mandible relative to a single point on mandible during all possible extreme movements CONTACT MOVEMENTS Produced during gliding when maxillary & mandibular teeth are in contact with each other FREE MOVEMENTS In this teeth do not come into contact with each other

PROTRUSION
Forward movement of mandible Muscles involved:1. Lateral pterygoid 2. medial pterygoid Muscle involvement is bilateral

RETRACTION
Backward movement of mandible Muscles involved:1. Temporalis (post. fibres) 2. Digastric (post. belly) Bilateral involvement

DEPRESSION
Downward movement of mandible Causes opening of mouth Muscles involved:1.Lateral pterygoid 2.Digastric(ant.belly) 3.Geniohyoid 4.Mylohyoid Muscle involvement is bilateral

ELEVATION
Upward movement of mandible Causes closing of mouth Muscles involved:1. Masseter 2. Temporalis 3. Medial pterygoid During this closure movement, head is retracted before elevation

ELEVATION R E T R A C T I O N
MASSETER MEDIAL PTERYGOID

TEMPORALIS

DIGASTRIC GENIOHYOID

LATERALPTERYGOID

MYLOHYOID

P R O T R U S I O N

DEPRESSION

TMJ DISORDERS
ETIOLOGY :Some factors proposed are: 1. Parafunctional habits 2. Emotional distress 3. Acute trauma from blows or imparts 4. Trauma from hyperextension 5. Instability of maxillomandibular relationships 6. Laxity of the joints 7. Comorbidity of other rheumatic or musculoskeletal disorders. 8. Poor general health and unhealthy lifestyle.

DIAGNOSTIC CLASSIFICATION
Diagnostic category Cranial bones (including the mandible ) Diagnosis Congenital and developmental disorders: aplasia, hyperplasia, hypoplasia,and dysplasia Acquired disorders :(neoplasia, fracture)

DIAGNOSTIC CLASSIFICATION
Diagnostic category Temporomandibular joint disorders Diagnosis Deviation in form Disk displacement with reduction , without reduction) Dislocation Inflammatory conditions (synovitis,capsulitis) Arthritides (osteoartheritis, osteoarthrosis) Ankylosis & Neoplasia

DIAGNOSTIC CLASSIFICATION
Diagnostic category Masticatory muscle disorder Diagnosis
Myofacial Myostitis Spasm Protective

pain

splinting Contracture

ASSESSMENT
Diagnostic assessment can be done using the following aids: 1. History 2. Physical examination 3. Range of mandibular movement 4. Palpation of masticatory movements 5. Palpation of cervical muscles 6. Palpation of TMJ 7. Assessment of parafuntional habits

8. Diagnostic imaging 9. Diagnostic LA nerve blocks

MYOFASCIAL PAIN OF MASTICATORY MUSCLES

Also called, Masticatory myalgesia syndrome TMJ pain dysfunction syndrome

Etiology:

Masticatory muscle spasm Muscle spasm is because of : - Muscular Overextension - Muscular Over contraction - Muscle Fatigue Chronic oral habits e.g. : grinding or clenching of teeth

Clinical features

1. 2. 3. 4.

Age : usually below 40 years Sex : females more than males Cardinal signs and symptoms : Pain Muscle tenderness Clicking noise in TMJ Limitation of jaw motion with deviation on opening

TRIGGER POINT THERAPY

It has used two modalities : The cooling of skin over the involved muscle and stretching The direct injection of LA into the muscle.

INTRACAPSULAR DISORDERS : ARTICULAR DISK DISORDER

DEFINATION :Articular disk displacement (ADD) is an abnormal relationship between the : -the disk -the mandibular condyle -and articular eminence, resulting from the stretching or tearing of the attachment of the disk of the condyle and the glenoid fossa.

ETIOLOGY
Trauma Bruxism

Clinical features
ADD is divided into stages on the basis of signs and symptoms combined with the results of imaging studies :
1. 2. 3.

Anterior disk displacement with reduction ADD with intermittent locking ADD without reduction (closed lock)

ADD WITH REDUCTION (CLICKING JOINT)

Due to loosening of articular disk because of : Elongation or tearing of restraining ligaments & has moved from its normal position on the top of the condyle. Chief complaint : Pain during mandibular movement. Pain is most noticeable at the time of a click.

ADD WITHOUT REDUCTION (CLOSED LOCK)

Detected more frequently in patients with clicking joints that progress to intermittent brief locking and then permanent locking. The limited mandibular opening occurs when disk interferes with the normal translation of the condyle along the glenoid fossa. Limited lateral movement Pain

POSTERIOR DISK DISPLACEMENT

2. 3. 4. 5.

Described as the condyle slipping over the anterior rim of the disk during opening with the disk being caught and brought back ward in an abnormal relation to the condyle when the mouth is closed. c/f : 1. sudden inability to bring the upper and lower teeth together in maximal occlusion, Pain Displacement forward of the mandible on the affected side. Restricted lateral movements on affected side No restriction of mouth opening

MANAGEMENT

Recommended treatments for symptomatic ADD include - splint therapy -Manual manipulation & other forms of physical therapy -Anti-inflammatory drugs -Arthrocentesis -Arthroscopic lysis & lavage -Arthroplasty -Vertical ramus osteotomy

ADD WITH REDUCTION (CLICKING JOINT)

Flat plane stabilization splints

Anterior repositioning splint

ADD WITHOUT REDUCTION (CLOSED LOCK)

Nonsurgical and surgical Nonsurgical : 1. Manual manipulation 2. Exercise program 3. Flat plane occlusal stabalization appliance 4. Anti-inflammatory drugs Surgical : 1. Arthrocentesis 2. Arthroscopy

DEGENERATIVE JOINT DISEAES (OSTEOARTHRITIS)

It is primarily a disorder of articular cartilage and subchondral bone, with secondary inflammation of the synovial membrane. CLINICAL FEATURES Incidence increases with age Inflammation and joint effusions Clicking, snapping or unilateral pain over the condyle occurs Crepitus Limitation of opening Destruction of disc may also occur.

RADIOGRAPHIC FEATURES
Narrowing of the joint space, irregular joint space, flattening of the articular surfaces, osteophytic formation, anterior lipping of the condyle, and the presence of Elys cysts.

Treatment
Conservative therapy includes Nonsteroidal anti-inflammatory medications; Heat ; soft diet; rest ; and occlusal splints treat myofascial pain or meniscal defects. Intra-articular steroids

Synovial Chondromatosis CHONDROMETAPLASIA

Synovial chondromatosis (SC) is an uncommon benign disorder characterized by the presence of multiple cartilagenous nodules of the synovial membrane that break, off resulting in clusters of free-floating loose calcified bodies in the joint. It is theorized that SC originates from embryonic mesenchymal remnants of the subintimal layer of the synovium that become metaplastic, calcify, and break off into the joint space

CLINICAL MANIFESTATIONS
Slow progressive swelling in the pretragus region, Pain , and limitation of mandibular movement TMJ clicking, locking, crepitus, and occlusal changes Intracranial extension may lead to neurologic deficits such as facial nerve paralysis.

TREATMENT
Treatment should be conservative and consist of removal of the mass of loose bodies. This may be done arthroscopically when only a small lesion is present, but arthrotomy is required for larger lesions.

Rheumatoid Arthritis
The disease process starts as a vasculitis of the synovial membrane. It progresses to chronic inflammation marked by an intense round cell infiltrate and subsequent formation of granulation tissue. The cellular infiltrate spreads from the articular surfaces eventually to cause an erosion of the underlying bone.

CLINICAL MANIFESTATIONS

The TMJs are usually bilaterally involved in RA. limitation of mandibular opening and joint pain. Pain is usually associated with the early acute phases of the disease but is not a common complaint in later stages. Other symptoms often noted include morning stiffness, joint sounds, and tenderness and swelling over the joint area.

TREATMENT

Flat plane occlusal appliance may be helpful, particularly if parafunctional habits are exacerbating the symptoms. An exercise program to increase mandibular movement should be instituted as soon as possible after the acute symptoms subside. When patients have severe symptoms, the use of intra-articular steroids should be considered.

Surgical treatment of the joints including placement of prosthetic joints, is indicated in patients who have severe functional impairment or intractable pain not successfully managed by other means.

Psoriatic Arthritis
Psoriatic arthritis (PA) is an erosive polyarthritis occurring in patients with a negative rheumatoid factor who have psoriatic skin lesions.251 The skin lesions precede the joint involvement by several years.

CLINICAL MANIFESTATIONS
The symptoms of PA of the TMJ are similar to those noted in RA Radiographic findings: show erosion of the condyle and glenoid fossae rather than proliferation.

Treatment
physical therapy and NSAIDS Immunosuppressive drugs, Only when there is intractable TMJ pain or disabling limitation of mandibular movement is surgery indicated. Arthroplasty or condylectomy with placement of costochondral grafts has been performed successfully.

Septic Arthritis
Septic arthritis of the TMJ most commonly occurs in patients with previously existing joint disease such as rheumatoid arthritis, or underlying medical disorders (particularly diabetes). Patients receiving immunosuppressive drugs or long term corticosteroids also have an increased incidence of septic arthritis. Gonococci are the primary blood borne agents causing septic arthritis in a previously normal TMJ while Staphylococcus aureus is the most common organism involved in previously arthritic joints

CLINICAL MANIFESTATIONS
Trismus Deviation of the mandible to the affected side, Severe pain on movement, An inability to occlude the teeth, owing to the presence of inflammation in the joint space. Examination reveals redness and swelling in the region of the involved joint. The swelling may be fluctuant and extend beyond the region of the joint. Large tender cervical lymph nodes are frequently observed on the side of the infection; TREATMENT Treatment of septic arthritis of the TMJ consists of surgical drainage, joint irrigation, and 4 to 6 weeks of antibiotics.

DEVELOPMENTAL DISTURBANCES

Include a) aplasia of mandibular condyle b) hypoplasia of mandibular condyle c) hyperplasia of mand condyle

APLASIA
Mandibular condyle fails to develop Unilateral or bilateral disease

Clinical features
Defective or absent external ear Underdeveloped mand ramus or macrostomia In unilateral aplasia -Facial asymmetry occurs -Both occlusion & mastication altered -Mand. shift towards affected side In bilateral cases mand. shift is not present

TREATMENT
Osteoplasty Malocclusion corrected by orthodontic appliances Cosmetic surgery( for facial deformity)

HYPOPLASIA
Underdeveloped or defective formation of condyle It may be congenital or acquired CLINICAL FEATURES: Facial asymmetry in unilateral cases In mild disturbance there is slight mandibular shifting from midline

TREATMENT

Cartilage or bone transplants preceded by osteotomy

HYPERPLASIA
Unilateral enlargement of condyle. ETIOLOGY Mild chronic inflammation

CLINICAL FEATURES Unilateral slowly progressive elongation of face. Deviation of chin away from affected side. Severe Malocclusion occurs

TREATMENT Resection of condyle

TRAUMATIC DISTURBANCES
Include a) Luxation & subluxation b) Ankylosis c) Fractures of condyle

LUXATION & SUBLUXATION

Dislocation occurs when head of condyle moves anteriorly into such a position that it cannot be returned voluntarily to its normal position.

ETIOLOGY Traumatic injury Yawning or opening the mouth too widely CLINICAL FEATURES Sudden locking & immobilization of jaws when mouth is opened. Mouth cannot be closed

TREATMENT Relaxation of muscles Moving the mandible to its position by exerting inferior & post. pressure of thumbs in mandibular molar areas.

FRACTURES OF CONDYLE
ETIOLOGY Traumatic injury CLINICAL FEATURES Limitation of motion Pain & swelling over involved condyle

TREATMENT

ANKYLOSIS
Hypomobility ETIOLOGY Traumatic injury Infections in & about the joints CLINICAL FEATURES Patients may not able to open the mouth to appreciable extent. Facial deformity occurs TREATMENT Surgical

NEOPLASTIC DISTURBANCES
Neoplasms or tumor like growths benign or malignant may involved TMJ. Some tumors may originate from condyle or from joint capsule. Metastatic tumors have also been reported to involve TMJ.

EXTRAARTICULAR DISTURBANCES
Sinusitis & middle ear disease often caused pain in joint. Other conditions like cellulitis, odontalgia, neuritis of trigeminal n. also causes pain in joint.