Temporo mandibular

joint

By : Asma Elserity

*Introduction *Anatomy

*Radiographic examination *Myo functional pain dysfunction syndrome

*TMJ disorder *Dx of TMJ disorder *Rx of TMJ disorders

Objectives

Definition:

It is the joint formed by temporal bone with the mandibleIt`s actually a sliding joint not only ball & socket

Site: In front of

each ear

Structure of TMJ

1 -articulating surfacesA (bony elements)

condyle

Glinoid fossa

Interatricular disc

Cartilaginous disc placed between the 2 bony elements

The disc is attached to a muscle (lateral pterygoid) & moves with certain movement of TMJ

Joint capsuleIt surrounds TMJ

It is attached to glinoid fossa margin & the neck of condyle

*It maintain proximity of joint parts during function

*It limits forward translation of the condyle

Synovial membrane It is the internal lining of external capsule

It contains synovial fluid for lubricating the joint

Symptoms of TMJ

disorder

Diagnosis of TMJ disorder

Comprehensive history(onset,duration,course,pasthistory,surgical procedures,family history)

Physical examination(palpation ,stethoscope,dentition)

Radiographic diagnosis

Lab investigations

Radiographic examination

To evaluate condition of teeth , bone ,surrounding hard & soft tissue

(aPlain x-ray

To see changes in bony structure only Ex : panoramic , oblique lateral

Tomography

It is of a great value in dx of TMJD…It has the property of elimination of superimposition in plain x rays

Arthrography

They r taken after injecting die material into synovial spaces to enhance intra capsular soft tissue

C.T scan

It`s x-ray images in serial manner with different levels showing hard & soft structures v. Helpful in Dx of TMJD inspite of high dose of exposure

MRI

It`s efficient in detecting changes in soft tissues

Limited accuracy in detecting bony elements

Helpful in DX of (internal derangement)

Arthroscopy

It allows detection of internal abnormality by direct vision through arthroscope

synovial

chondroma

tosis

Lab investigations CBC

Serum calciumSerum phosphorus & alkaline phosphataseSerum uric acid

ESRSerum RF

functionalMyofunctional pain dysfunction syndrome

Organic

Acquired (arthritis-dislocation-ankylosis-internal derangement)

Congenital (condylar hypo/hyperplasia)

TMJ disorders

It`s a painful condition of skeletal muscles specially the muscles of mastication

Characterized by development of trigger points or sensitive painful area in muscle or junction bet muscle & facia

Myofunctional pain

dysfunction syndrome

This trigger points is locally tender

It may produce ANS stimulation as flushing .

Sweeting & hypersensitivity in these areas

Incidence: male = female

From 15-60 yrs

Signs & symptoms

1 -Pain-it`s the most complain

-mostly unilateral -dull - sharp & acute

LocationBack of head & neckTemporal areaAngle of jawThe area in front of ear

2-tenderness of muscles of masticationTemporal muscle

is the common muscle to produce temporal pain

Masseter : trigger points Refer pain to : (sinus area,Ear , above eye & even into molar region)

Trapezius muscle: Pain almost referred to head & face

Medial pterygoid muscle: Trigger points refer to ( TMJ,

nose ,ear , lower jaw & lateral side of neck )

Sternomastoid muscle:Develops trigger points withor

w/out TMJ problems

Cause forehead headache( misdiagnosed with frontal sinusitis)

Also may cause pain in (ear, over &around aye ,chin & below the eye (mis diagnosed with max sinusitis ) )

3-clicking in TMJ during movement

-It is the most common symptom (it may be so loud )

-There may be pain in joint during chewing

4 -limitation of mandibular movement

5-absence of clinical or radiographic evidence of

Organic changes in TMJ

6 -No tenderness of TMJ during examination

Etiology of MPD

occlusal disharmony psychological stress

Diagnosis of MPD

1 -History.

2-Determine the range of mouth opening.

3 -Radiographic examination showing no organic changes.

4-Determine the direction & amount of mandibular deviation during opening.

5-Examination of TMJ by palpation & auscultation & palpation of muscles of mastication

Treatment of MPD

Removal of psychological

stress & tension

Correction of occlusal

disharmony

Control pain & discomfort

Immobilization of jaw It produce complete rest for 2-3 weeks

Use of Boxer`s mouth guard (to separate occlusal surfaces )

Correction of occlusal disharmony

1 -occlusal adjustment : by selective grinding to remove cusp interference between teeth

To maintain occlusal stability & equilibrium of muscle during rest position

2 -Anterior deprogrammer: *Suppresses clenching intensity

**Prevent occlusal wear & trauma

3-splints & occlusal bite planes: Acrylic splints made with simultaneous contact of mandibular teeth in

centric occlusionto eliminate muscular spasm

Thermo therapy

By heat application to activate blood circulation of spastic muscles

Muscle exercise

It stimulate weak muscles & wash metabolites so decrease spasm

Intra muscular injection of L.A: Help in diagnosis of the syndrome & in cuts cycle

of pain

Psychological therapy

Emotional stress stimulate vascular dynamics (contraction & dilatation ) so increasing muscular tone leading to spasm

Administration of muscle relaxant

Acquired organic disorders of TMJ

1 -Inflammatory .

2 -Degenerative.

3 -Infectious.

4 -Traumatic.

Rheumatoid arthritis It`s a systemic inflammatory disease that produce destructive changes to the joints (may affect more than one joint )

c/p:Pain , joint noise ,limitation of

movement , malocclusion) Juvenile RA : impairment of jaw growth & may lead to ankylosis

Diagnosis of R.A Clinically : multiple joint involvement

Lab investigations : RH factorRadiographic examination : (lack of joint space d.t condylar destruction )

-Condyle is eroded ,flattened & rarefied -Glinoid fossa is shallow

Treatment

*application of moist heat *anti inflammatory drugs

*immunosuppressive drugs *Gold salts

*steroids (oral – joint injection)

Degenerative arthritis (osteoarthritis)

Non inflammatory focal degenerative disorder that affect primarily articular cartilage and sub condylar bone (initiated by deterioration of articular soft tissue cover & exposure of bone )

Cause : long term functional abuse

C/P: * Crepitation sound from joints

*Restricted or normal mouth opening*With or w/out pain

*Occasionally may joints show inflammatory signs*Women > Men

*Tenderness of muscles of mastication *Limitation of mandibular movement & deviation

to the affected side *Tenderness over condyle

Diagnosis

Based on clinical & radiographic examination (irregularity of condylar surface & radiolucency in substance of condyle )

Treatment

Analgesics Anti inflammatory drugsMuscle relaxant

Surgery (condylar shaving or high condylectomy )

Infectious arthritis

It is the consequence of direct extension from middle ear , parotid gland & posterior areas of mandible

it is also happened after trauma followed by infection from septseamiaLeads to inflammation of synovial tissuesLeads to destruction of fibro cartilage & bone leading to ankylosis

Treatment

Administration of antibiotics

Drainage of source of infection

Rest

analgesics

Traumatic arthritis

Occurs d.t trauma to the jointThere is muscular tear , ligamentous injury

Hemarthrosis may be presentMechanical damage to surrounding structure may be

present

Diagnosis

History of severe trauma with pain , swelling , & dysfunction Only the affected joint showing inflammation

Presence of normal joint function before trauma

Treatment : Rest , Administration of analgesics , anti inflammatory drugs

Congenital condylar disorders

Condylar hypoplasia

Condylar hyperplasia

Others

Benign tumors

1 -synovial chondromatosis: Benign tumor characterized by cartilaginous metaplasia of synovial membrane producing small nodules which separate form membrane to become loose bodies that may ossify

2 -osteochondroma

Benign tumor characterized by normal bone & cartilage near growth zones

Osteoma

Osteoma is a benign tumour consistingof mature bone tissue.It is a slow growing, asymptomatic

Dislocation of TMJ

Anterior (to

eminence)

Superior (into medial

cranial fossa)

Posterior (in fracture of

base of skull )

Lateral (in temporal

fossa)

Signs & symptoms of dislocation -Mandible fixed in open position

-Protrusion of chin

-Deviation to the normal side

-By palpation depression is noticed in front of the ear

-Limitation of movement -Pain

Treatment of dislocation Acute dislocation:

Manual reduction under sedation or even under G.A with muscle relaxant

Then immobilization for several days..

Chronic dislocation -Manual reduction with L.A or G.A & muscle

relaxant -Surgical exposure of joint & direct reduction

-Condylectomy -Condylotomy

3 -Recurrent dislocation Conservative RX : immobilization for several daysInjection of sclerozing material around capsule to produce fibrosisSurgical RX : re-situation of capsule & ligamentLigation of condyle

Removal of eminenceRemoval of activating muscle

TMJ ankylosis

It is fibrous or bony union between joint components

It is unilateral or bilateral Partial or complete

True or false (When the structures outside the joint are affected)

False ankylosis

Muscular trismus

Muscular atrophy or fibrosis

Myositis ossificans Tetanus

Neurogenic closure of mouth

Etiology

Birth trauma Heamarthrosis Suppurative arthritis

Rheumatoid arthritisOsteomyelitisFracture condyle

Clinical findings

-Inability to open mouth

-Gradual development of jaw immobilization

-Slight opening mouth in unilateral affection

-Bird face ,micrognathia, mal occlusion & impacted teeth

-Deviation of mandible to the affected side

Treatment

*If fibrous ankylosis : Open the mandible

manually under G.A

*Condylectomy *Osteoarthrotomy

*Repalcement of condyle

Internal derangement of TMJ

Abnormal relationship between articular disc to condyle & eminence

Symptoms

Pain during function Joint clicking or noise

Earache or headacheFacial pain

Ant. Displacement of the disc (with reduction)(clicking)

Ant. dislocation of the disc (w/out reduction) (locked joint).

TreatmentConservative treatment

Occlusal therapy :Selective grinding.Construction of splints.

Physiotherapy :Soft diet , muscular exercises.Muscle relaxants.

Surgical treatmentRelocation of disc:

meniscoplastyCondylotomy.

Capsular rearrangement of the meniscus.

High condylectomy