Temporomandibular Joint Disorders

INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Temporomandibular Joint
Disorders
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Embryology- TMJ
Anatomy- TMJ
Classification – TMJ Disorders
Internal derang...
Embrylogy – TMJ
• TMJ develops between 7th & 12th week of
gestation from two separate
blastemas.(Temporal, Condyle)
• Supe...
Embrylogy – TMJ…
• In the centre of the condyle, Cartilage
develops → Secondary Cartilage
Endochondral Ossification

Subch...
Embrylogy – TMJ…
• The developing disk is highly cellular & vascular
• It continues anteriorly with Lat.pterygoid muscle &...
Embrylogy – TMJ…
• Pinto’s ligament: / Discomalloelar ligament
• Described by Pinto -1962
• “Fibrous link between the poas...
Anatomy - TMJ
• “Uniqueness” of the TMJ- Stegenga B, DeBont
LGM et al, JOMS 47:249-256 1989
• Bilateral articulation with ...
Anatomy - TMJ
• Ginglimo-di arthroidal
• Synovial Joint
• Boundaries:

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Anatomy – TMJ…
 Components of TMJ
Bony
 Mandibular condyles
 Articular surfaces of
the temporal bone.
Soft tissue
 Cap...
Anatomy – TMJ…
Mandibular condyle.
 Articulating surface
 Condylar head strongly convex in the anteroposterior direction...
Anatomy – TMJ…
Temporal bone: - Squamous partGlenoid fossa
Articular eminence
Post glenoid tubercle

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Anatomy – TMJ…
CAPSULE:
TMJ is enclosed in a thick
fibrous capsule.
Capsule attachments:
• superiorly: articular
eminence ...
Anatomy – TMJ…
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Articular disc:
Fibrocartilage,viscoelastic
Avascular,Non innervated
Bi concave
Ant. ,Post.bands...
Anatomy – TMJ…
• Articular Disc:
• Medio;lateral: Check Lig.
• Superior &Inferior joint cavities

• Superior joint cavity-...
Anatomy – TMJ…
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Articular Disk – Functions:
Shock absorber of Joint
Prevents bone- bone contact
Viscoelastic pro...
Anatomy – TMJ…
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Ligaments:
Primary:
Capsular ligament
Diskal ligaments
Accessory:
Sphenomandibular
Stylomand...
Anatomy – TMJ…

Sphenomandibular Ligament
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Anatomy – TMJ…

Stylomandibular Ligament
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Anatomy – TMJ…
• Blood supply:
• Lateral aspect- Superficial Temporal artery
• Medial & posterior aspect of disk& condyle
...
Anatomy – TMJ…

“ Circulus articuli / vasculosus of william hunter.”
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Anatomy – TMJ…

Arterialwww.indiandentalacademy.com
& Nerve supply
Anatomy – TMJ…
• INNERVATION OF
TMJ
• Auriculotemporal
nerve
• Masseteric nerve
• Deep temporal nerve
• Mechanoceptors
• N...
Classification of TMJ Disorders
• Masticatory muscle disorders :- MPDS
• Temporo mandibular joint disorders:
A) Disk displ...
Classification of TMJ Disorders
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E) Trauma- Condylar #
F) Tumors, Cysts
G)Infections
H)Growth disorders:
Agenesis, Hypop...
Internal Derangement of
Internal Derangement Of TMJ
Temporomandibular Joint

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Biomechanics of normal TMJ
• The condyle functions in both a hinge and a sliding
fashion. During full opening the condyle ...
Biomechanics of normal TMJ
• Normal tmj – Postion
of disk
Posterior band --12 o’
clock
Intermediate zone—
1 o’clock

www.i...
Biomechanics of normal TMJ

Stretching of bilaminar zone & retrodiskal tissues
→ forward movement of disk
→ condylar trans...
But..
• Prolonged overloading of Joint
• Chronic Macro & Micro trauma – joint
• Dental &/ skeletal malocclusions
• Oromand...
Internal derangement of TMJ
• Hey & Davies (1814) – ― a localized
mechanical fault interfering with smooth
action of a joi...
Internal derangements of TMJ…
Staging of internal derangement – Wilkes system:
Stage-I: Early reducing disk displacement
S...
Internal derangement of TMJ…
• Clinical features & physical examination:
• Opening & reciprocal click(Stage-I or II)
• Joi...
Internal derangement of TMJ…
• Clinical features & physical
examination:contd.
• Crepitus – Chronic disk displacement with...
ASSESSMENT OF SOUNDS FROM TMJ

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Internal derangement of TMJ…

Disk displacement with reduction – (Wilkes stage-I/II)
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Internal derangement of TMJ…

Disk displacement with reduction – (Wilkes stage-I/II)
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Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings

• Stage-...
Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
Stage-II
...
Internal derangement of TMJ…

No Clicking

Disk displacement without reduction – (Wilkes stage-III/IV)
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Internal derangement of TMJ…

Disk displacement without reduction – (Wilkes stage-III/IV/V)
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• ―A clicking joint doesn’t lock & a locking
joint doesn’t click‖ - Farrar et al

Current advances in Oral Surgery Vol.III...
Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings

• Stage-...
Internal derangement of TMJ…
Wilkes Stage- IV & V

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Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings

• Stage-...
Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
• Stage-V...
Pathophysiology Of Disk
displacements
• Disk displacements– Adaptive response
Pseudo disk Formation,
Remodelling of condyl...
Pathophysiology Of degenerative
joint disorders
• Mechanisms of Injury:
• 1.DIRECT MECHANICAL TRAUMA:
• Trauma (mechanical...
Pathophysiology Of degenerative
joint disorders
• 3.NEUROGENIC INFLAMMATION
• In cases of disk displacement the compressio...
Pathophysiology Of degenerative
joint disorders
• MECHANISMS OF TISSUE
DEGRADATION:
• 1. Enzymatic degradation
(metallopro...
“Sequential pathogenesis of degenerative changes of articular
cartilage”
Quinn JH, Oral Maxillofac Surg Clin North Am 1:47...
Chronic
Non reducing Disk
displacement
Degenerative
joint disease/
Osteoarthrosis

Joint over loading

Disk
Deformation

F...
Degenerative changes -TMJ

Osteoarthrosis of condyle with disc displacement
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Degenerative changes -TMJ

Disk perforation
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Evaluation of the patient with disc
displacement & investigations
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1. Case history
2. Physical exami...
Treatment – Internal
derangement
Treatment for all pts with disc displacement ???
Disc displacement ---35 % asymptomatic v...
• Self remission of internal derangements??

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Treatment – disk displacement
disorders
• Sato S, Takahashi K, et al “The natural course of nonreducing
disc displacement ...
Treatment – Disk displacement
disorders
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Conservative Treatment:
AIMS:
Reducing pain and discomfort
Decreasing i...
Treatment – Disk displacement
disorders
1. PATIENT EDUCATION
• Awareness about the pathology
• Discontinuation of parafunc...
Treatment – Disk displacement
disorders
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2. MEDICAL MANAGEMENT :
1. NSAIDs
2. Muscle relaxants
3. Tricyclic an...
Treatment – Disk displacement
disorders
• “Treatment of severe TMJ clicking with botulinum
toxin in the lateral pterygoid ...
Treatment – Disk displacement
disorders
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3.PHYSICAL THERAPY
1. Isometric jaw exercises
2. Ultrasound ( 0.7 to ...
4.Splint therapy – TMJ disk
displacement disorders
• RATIONALE FOR THE USE OF SPLINT
THERAPY
• “Unloading the joint” / ↑Jo...
Types of splints
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Stabilization splint
Repositioning splint
Mandibular orthopedic repositioning splint
Pivot s...
• PERMANENT OCCLUSAL
MODIFICATION
• Occlusal equilibration
• Prosthetic restoration
• Orthodontics
• Orthognathic surgery
...
• “Orthodontic treatment of TMJ disc
displacement with pain: an 18 year
follow-up”
Ugo Capurso, Ida Marini
Progress in ort...
• “Temporomandibular joint dysfunction and
orthognathic surgery: a retrospective study”
Jean-Pascal Dujoncquoy, Joël Ferri...
Surgical treatment – Disc
displacement disorders
• Indications:
• Patients unresponsive to conservative Rx
• Wilke’s stage...
Surgical treatment Options –
Internal Derangement
1.Artrhrocentesis
2.Arthroscopy
3.Arthrotomy + Disc repair
4.Arthrotomy+...
1.Arthrocentesis:
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Minimally invasive Sx procedure
↓ Local anestheisa +/- Sedation
Rationale:
a)Washes out inflamm...
Arthrocentesis
• Indications:
• ID pts refractory to conservative Rx
• Effective in anterior disc displacement
without red...
Arthrocentesis
• Irrigation with Ringer’s lactate
• 1ml of hydrocotisone.

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2.ARTHROSCOPY
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INDICATIONS OF ARTHROSCOPY
1. Internal derangement
2. Osteoarthritis
3. Arthritides
4. Pseudotu...
ARTHROSCOPY
• Placement of cannula into superior joint
space
• Arthroscope with light source is inserted
• Video camera an...
Arthroscopic procedures :

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1. Lavage
2. Lysis
3. Disk repositioning
4. Lateral capsule release
5. Synovecto...
Arthroscopy

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Arthroscopy
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COMPLICATIONS :
1. Vascular injury
2. Extravasation
3. Scuffing of the cartilage
4. Broken ...
Fridrich KL et al . “Prospective comparison of arthroscopy and
arthrocentesis for temporomandibular joint disorders.”
J Or...
Murakami K, et al. “Short-term treatment outcome study for
the management of temporomandibular joint closed lock. A
compar...
TMJ Surgery
• Surgical approaches:
• Preauricular incision (Dingman’s)
• Modified preauricular incisions
(Thoma’s,Blair’s,...
Incisions on capsule

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3. Arthrotomy + Disc Repair:
PLICATION:
• Chronic non reducing disc displacements
• A wedge of retrodiscal tissue is remov...
3. Arthrotomy + Disc Repair:
• DISK PLICATION:

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4.Arthrotomy+ Disk repositioning
• Condylar Diskopexy:
• In Wilke’s stage –III,IV disk displacements
• Displaced disk free...
Condylar Diskopexy

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Arthrotomy+ Disk repositioning
• Temporal diskopexy:
• In Wilke’s stage IV cases with too
deformed disks
• Bur holes drill...
Diskopexy- bone anchors

―Temporomandibular joint disc
repositioning using
bone anchors: an immediate
post surgical evalua...
5.Arthrotomy+diskectomy
• Wilkes stage IV & V , disks with
perforations & severe degenerative
changes
• Cases with relapse...
6.Arthrotomy+diskectomy+autogenous
graft
• ―There is little evidence to suggest that
autogenous graft disk raplacement is
...
Arthrotomy+diskectomy+autogenous
graft
• Options:
• Auricular cartilage
• Dermis

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Arthrotomy+diskectomy+autogenous
Flap

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7.Condylotomy
• Popularized by Ward1952
• Creation of a
displaced condylar
neck #
• Condyle repositons
antero-inferiorly
•...
Hall’s Modified Condylotomy
• Vertical subcondylar
osteotomy
• Open osteotomy
procedure
• More controlled
approach to cond...
Recent advances – Rx of Internal
Recent articles on Mgmt of TMJ
Internal derangementRRecent
derangement

www.indiandentala...
• “Pterygoid Plate Disjunction: Minimally Invasive
Treatment for Internal Derangement of the
Temporomandibular Joint”
Varg...
“Pterygoid disjunction for internal derangement of
Temporomandibular joint”
Rohit Sharma.
J.Maxillofac.Oral surg.Apr-Jun20...
Randomized Effectiveness Study of Four Therapeutic
Strategies for TMJ Closed Lock
E.L. Schiffman, J.O. Look et al
J Dent R...
Chronic Recurrent dislocation of
Condyle
• Recurrent dislocation of
condyle out of the fossa
& anterior to eminece.
• Pred...
Chronic Recurrent dislocation of
Condyle- TREATMENT
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Miller & Murphy (1976)*:
1.Capsular tightening procedures...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• 1.Capsular tightening procedures:
• Chemical sclerosants: Sod...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• 2.Creation of
mechanical obstacle:
• A)Eminence
augmentation
...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• iii)Gossarez & Dautry:

• iV)Findlay: L shaped pins
www.india...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• 3.Direct restraint of condyle:
• Gordon– Fascia lata, sutured...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• 4.Creation of new muscle balance:
• Ward’s condylotomy
• Goul...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• 5.Removal of mechanical obstacles:
• A)Annandale 1887--- Disc...
Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
C) Condylectomy:

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Recent articles – TMJ
dislocation
―Evaluation of the mechanism and principles of
management of temporomandibular
jointdisl...
Key to success ---PG Exams
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Articles / Authors
Books
Charts/flowcharts/algorithms..
Diagrams
E...
Suggested Reading:
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Peter.D.Quinn: Atlas of TMJ surgery
Irby:Volume -3 TMJ Disorders
Norman & Bramley- TMJ Disorde...
Thank YOU
www.indiandentalacademy.com
Leader in continuing dental education

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Temparo mandibular joint disorders /certified fixed orthodontic courses by Indian dental academy

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Temparo mandibular joint disorders /certified fixed orthodontic courses by Indian dental academy

  1. 1. Temporomandibular Joint Disorders INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Temporomandibular Joint Disorders • • • • • • Embryology- TMJ Anatomy- TMJ Classification – TMJ Disorders Internal derangement Degenerative joint disease Chronic recurrent dislocation - TMJ www.indiandentalacademy.com
  3. 3. Embrylogy – TMJ • TMJ develops between 7th & 12th week of gestation from two separate blastemas.(Temporal, Condyle) • Superior to condylar blastema, a band of mesenchymal cells defferentiate to form articular disk. • Temporal & Condylar blastemas →Osteoblasts →Membranous bone www.indiandentalacademy.com
  4. 4. Embrylogy – TMJ… • In the centre of the condyle, Cartilage develops → Secondary Cartilage Endochondral Ossification Subchondral Bone Formation Enlargement of the condyle in adulthood in adaptation to overloading www.indiandentalacademy.com
  5. 5. Embrylogy – TMJ… • The developing disk is highly cellular & vascular • It continues anteriorly with Lat.pterygoid muscle & posteriorly by a ligament with superior end of Meckel’s cartilage that develops in to malleus of middle ear. – Discomalleolar ligament / Pinto’s ligament * • In post natal life pinto’s lig. Inserts most of its fibers into squamo tympanic fissure & loses its attachment to the malleus. *- Viva Question www.indiandentalacademy.com
  6. 6. Embrylogy – TMJ… • Pinto’s ligament: / Discomalloelar ligament • Described by Pinto -1962 • “Fibrous link between the poasteromedial aspect of articular disk & anterior process of malleus of middle ear seen in fetal tm joints” • In adults the ligament is present, but looses its attachment to malleus • Loughner et al -1989: dissection 14 cadaveric heads, showed that only one had anatomic continuity to malleus www.indiandentalacademy.com
  7. 7. Anatomy - TMJ • “Uniqueness” of the TMJ- Stegenga B, DeBont LGM et al, JOMS 47:249-256 1989 • Bilateral articulation with the cranium • Occlusion and articulation of teeth affect joint movement and condylar positions • Articular surfaces are fibrocartilage rather than hyaline cartilage • TMJ contains an articular disc www.indiandentalacademy.com
  8. 8. Anatomy - TMJ • Ginglimo-di arthroidal • Synovial Joint • Boundaries: www.indiandentalacademy.com
  9. 9. Anatomy – TMJ…  Components of TMJ Bony  Mandibular condyles  Articular surfaces of the temporal bone. Soft tissue  Capsule.  Articular disc.  Ligaments.  Lateral pterygoid Muscle www.indiandentalacademy.com
  10. 10. Anatomy – TMJ… Mandibular condyle.  Articulating surface  Condylar head strongly convex in the anteroposterior direction & slightly convex in the medio-lateral direction.  Lat. & Medial poles – check ligaments  Condylar neck –pterygoid fovea - lateral pterygoid muscle. www.indiandentalacademy.com
  11. 11. Anatomy – TMJ… Temporal bone: - Squamous partGlenoid fossa Articular eminence Post glenoid tubercle www.indiandentalacademy.com
  12. 12. Anatomy – TMJ… CAPSULE: TMJ is enclosed in a thick fibrous capsule. Capsule attachments: • superiorly: articular eminence & the circumference of the mandibular fossa. • Inferiorly: neck of the condyle. • Laterally - thickened temporo-mandibular ligament. www.indiandentalacademy.com
  13. 13. Anatomy – TMJ… • • • • • Articular disc: Fibrocartilage,viscoelastic Avascular,Non innervated Bi concave Ant. ,Post.bands & intermed. • Ant.—Lat.pteryg.musc • Post.--- Bilaminar Zone • Retrodiscal tissue www.indiandentalacademy.com
  14. 14. Anatomy – TMJ… • Articular Disc: • Medio;lateral: Check Lig. • Superior &Inferior joint cavities • Superior joint cavity-sliding --- Volume --- 1.2ml • Inferior joint cavity-rotatory --- Volume --- o.9ml Coronal Section - TMJ www.indiandentalacademy.com
  15. 15. Anatomy – TMJ… • • • • • Articular Disk – Functions: Shock absorber of Joint Prevents bone- bone contact Viscoelastic property? Keratan sulfate, Glycosaminoglycans - -Chondroitin 4 sulfate, -GAG Hyaluronic acid & Link proteins • GAG are distributed in load bearing areas • GAG-absorb water-allows disk to absorb stresses by deforming & leaking water. • On relief from stress, water content restored & loaded tissue returns to original shape www.indiandentalacademy.com
  16. 16. Anatomy – TMJ… • • • • • • • Ligaments: Primary: Capsular ligament Diskal ligaments Accessory: Sphenomandibular Stylomandibular www.indiandentalacademy.com
  17. 17. Anatomy – TMJ… Sphenomandibular Ligament www.indiandentalacademy.com
  18. 18. Anatomy – TMJ… Stylomandibular Ligament www.indiandentalacademy.com
  19. 19. Anatomy – TMJ… • Blood supply: • Lateral aspect- Superficial Temporal artery • Medial & posterior aspect of disk& condyle ---Deep auricular .A, Posterior auricular.A, Maxillary artery Masseteric artery www.indiandentalacademy.com
  20. 20. Anatomy – TMJ… “ Circulus articuli / vasculosus of william hunter.” www.indiandentalacademy.com
  21. 21. Anatomy – TMJ… Arterialwww.indiandentalacademy.com & Nerve supply
  22. 22. Anatomy – TMJ… • INNERVATION OF TMJ • Auriculotemporal nerve • Masseteric nerve • Deep temporal nerve • Mechanoceptors • Nociceptors www.indiandentalacademy.com
  23. 23. Classification of TMJ Disorders • Masticatory muscle disorders :- MPDS • Temporo mandibular joint disorders: A) Disk displacement disorders / Internal derangement B) Degenerative joint disease C) Chronic recurrent dislocation D)Arthritides: Osteoarthritis, polyarthritides E)Ankylosis www.indiandentalacademy.com
  24. 24. Classification of TMJ Disorders • E) Trauma- Condylar # F) Tumors, Cysts G)Infections H)Growth disorders: Agenesis, Hypoplasia, Hyperplasia www.indiandentalacademy.com
  25. 25. Internal Derangement of Internal Derangement Of TMJ Temporomandibular Joint www.indiandentalacademy.com
  26. 26. Biomechanics of normal TMJ • The condyle functions in both a hinge and a sliding fashion. During full opening the condyle not only rotates on a hinge axis but also translates forward to a position near the most inferior portion of the articular eminence. • During function the biconcave disk remains interpositioned between the condyle and fossa, with the condyle remaining against the thin intermediate zone during all phases of opening and closing. www.indiandentalacademy.com
  27. 27. Biomechanics of normal TMJ • Normal tmj – Postion of disk Posterior band --12 o’ clock Intermediate zone— 1 o’clock www.indiandentalacademy.com
  28. 28. Biomechanics of normal TMJ Stretching of bilaminar zone & retrodiskal tissues → forward movement of disk → condylar translation www.indiandentalacademy.com
  29. 29. But.. • Prolonged overloading of Joint • Chronic Macro & Micro trauma – joint • Dental &/ skeletal malocclusions • Oromandibular dyskinesias… etc ↓ • Overstretching/laxity of retrodiskal tissues ↓ +/• Hyperactivity of Lateral pterygoid muscle ↓ • Malrelationship/ in-co-ordination of condyle-disc movement ↓ • Internal derangement of TMJ www.indiandentalacademy.com
  30. 30. Internal derangement of TMJ • Hey & Davies (1814) – ― a localized mechanical fault interfering with smooth action of a joint‖ • Laskin (1994) -- ― A disturbance in the normal antatomic relationship between the disc & the condyle that interferes with smooth movement of the joint & causes momentary catching, clicking,popping or locking ‖ www.indiandentalacademy.com
  31. 31. Internal derangements of TMJ… Staging of internal derangement – Wilkes system: Stage-I: Early reducing disk displacement Stage-II: Late reducing disk displacement Stage-III: Non reducing disk displacementAcute/subacute Stage-IV: Chronic Non reducing disk displacementStage-V: Stage-IV + Osteoarthrosis **Wilkes CH, Arch Otolaryngol Head Neck Surg 115:469-457 1989 www.indiandentalacademy.com
  32. 32. Internal derangement of TMJ… • Clinical features & physical examination: • Opening & reciprocal click(Stage-I or II) • Joint Pain & tenderness to palpation, on function • Deviation to affected side until clicking occurs • Limitation of mouth opening /Deviation of opening with lack of palpable translation ( stage-III – V) www.indiandentalacademy.com
  33. 33. Internal derangement of TMJ… • Clinical features & physical examination:contd. • Crepitus – Chronic disk displacement with perforation, degenerative changes (StageV) www.indiandentalacademy.com
  34. 34. ASSESSMENT OF SOUNDS FROM TMJ www.indiandentalacademy.com
  35. 35. Internal derangement of TMJ… Disk displacement with reduction – (Wilkes stage-I/II) www.indiandentalacademy.com
  36. 36. Internal derangement of TMJ… Disk displacement with reduction – (Wilkes stage-I/II) www.indiandentalacademy.com
  37. 37. Staging Criteria for Internal Derangements of the TMJ with Respect to Clinical, Radiologic and Surgical Findings • Stage- I • Clincal:-no mechanical symptoms, Reciprocal click +, no pain or limitation of ROM • Imaging:normal tomograms, good disc contours • Surgical: normal anatomic form, slight anterior displacement, passive clicking www.indiandentalacademy.com
  38. 38. Staging Criteria for Internal Derangements of the TMJ with Respect to Clinical, Radiologic and Surgical Findings Stage-II • Clinical: Few episodes of pain • • Imaging: Normal tomogram, slight forward displacement & slight thickening of posterior edge of disc Surgical: Anterior displacement, early anatomic deformity www.indiandentalacademy.com
  39. 39. Internal derangement of TMJ… No Clicking Disk displacement without reduction – (Wilkes stage-III/IV) www.indiandentalacademy.com
  40. 40. Internal derangement of TMJ… Disk displacement without reduction – (Wilkes stage-III/IV/V) www.indiandentalacademy.com
  41. 41. • ―A clicking joint doesn’t lock & a locking joint doesn’t click‖ - Farrar et al Current advances in Oral Surgery Vol.III- William Irby www.indiandentalacademy.com
  42. 42. Staging Criteria for Internal Derangements of the TMJ with Respect to Clinical, Radiologic and Surgical Findings • Stage-III: • Clinical: Multiple episodes of pain, joint tenderness, catching and locking, restriction of motion, pain with function • Imaging: Anterior displacement with moderate to marked thickening of the posterior edge, normal tomogram • Surgical: Marked anatomic deformity, displacement, adhesions, no hard tissue changes www.indiandentalacademy.com
  43. 43. Internal derangement of TMJ… Wilkes Stage- IV & V www.indiandentalacademy.com
  44. 44. Staging Criteria for Internal Derangements of the TMJ with Respect to Clinical, Radiologic and Surgical Findings • Stage-IV: • Clincal: Chronicity with variable and episodic pain • Imaging:abnormal tomograms, early to moderate degenerative changes • Surgical: Hard tissue degenerative remodeling changing of both bearing surfaces with osteophytes, no perforation www.indiandentalacademy.com
  45. 45. Staging Criteria for Internal Derangements of the TMJ with Respect to Clinical, Radiologic and Surgical Findings • Stage-V: • Clinical: Crepitus, variable and episodic pain, restriction of motion, functional impairment • Imaging: Anterior displacement with perforation, degerative arthritic changes • Surgical: Gross degenerative changes of hard and soft tissue, perforation of posterior attachments, osteophytes www.indiandentalacademy.com
  46. 46. Pathophysiology Of Disk displacements • Disk displacements– Adaptive response Pseudo disk Formation, Remodelling of condyle.. • Chronic disk displacements →DEGENERATIVE JOINT DISORDER www.indiandentalacademy.com
  47. 47. Pathophysiology Of degenerative joint disorders • Mechanisms of Injury: • 1.DIRECT MECHANICAL TRAUMA: • Trauma (mechanical overloading) → generation of free radicals →intracellular damage & reduction in the reparative capacity • 2.HYPOXIA - REPERFUSION INJURY • Increased intracapsular hydrostatic pressure (clenching & bruxing) ----- → hypoxia. • When the pressure in the joint is decreased and perfusion is reestablished, free radicals are formed leading to intracellular damage. www.indiandentalacademy.com
  48. 48. Pathophysiology Of degenerative joint disorders • 3.NEUROGENIC INFLAMMATION • In cases of disk displacement the compression or stretching of the nerve - rich retrodiscal tissue may result in release of pro-inflammatory neuropeptides. • The release of cytokines results in release and activation of prostaglandins, leukotrienes, and matrix-degrading enzymes. www.indiandentalacademy.com
  49. 49. Pathophysiology Of degenerative joint disorders • MECHANISMS OF TISSUE DEGRADATION: • 1. Enzymatic degradation (metalloproteinases,plasma proteinases) • 2. Nonenzymatic degradation • (superoxide radicals, hydroxyl radicals, NO) www.indiandentalacademy.com
  50. 50. “Sequential pathogenesis of degenerative changes of articular cartilage” Quinn JH, Oral Maxillofac Surg Clin North Am 1:47-57 1989 Stress bruxism ↓ Chronic micro trauma ↓ Compression & Shearing ↓ Chondrocyte damage --- collagenase ↓ Splitting of proteoglycan chain & water loss ↓ Loss of cartilage resilience & water reabsorption ↓ CHONDROMALACIA www.indiandentalacademy.com
  51. 51. Chronic Non reducing Disk displacement Degenerative joint disease/ Osteoarthrosis Joint over loading Disk Deformation Flattening – condyle,articular eminence *Osteophytosis Disk perforation www.indiandentalacademy.com
  52. 52. Degenerative changes -TMJ Osteoarthrosis of condyle with disc displacement www.indiandentalacademy.com
  53. 53. Degenerative changes -TMJ Disk perforation www.indiandentalacademy.com
  54. 54. Evaluation of the patient with disc displacement & investigations • • • • • • • • • • • 1. Case history 2. Physical examination 3. Radiographic evaluation a. Transcranial views b. OPG c. Tomograms d. Arthrography e. CT scans f. MRI g. Nuclear imaging 4. Psychologic evaluation www.indiandentalacademy.com
  55. 55. Treatment – Internal derangement Treatment for all pts with disc displacement ??? Disc displacement ---35 % asymptomatic volunteers. • 1. Katzberg RW, Westesson PL et al “ Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects.” J Oral Maxillofac Surg 1996; 54:147-53. • 2. Ribeiro RF, Tallents RH et al “ The prevalence of disc displacement in symptomatic and asymptomatic volunteers aged 6 to 25 years. ” J Orofac Pain 1997; 11:37-47. www.indiandentalacademy.com
  56. 56. • Self remission of internal derangements?? www.indiandentalacademy.com
  57. 57. Treatment – disk displacement disorders • Sato S, Takahashi K, et al “The natural course of nonreducing disc displacement of the TMJ : changes in condylar mobility and radiographic alterations at one-year follow-up.” Int J Oral Maxillofac Surg 1998; 27:173-7. • 44 subjects who agreed to observation without treatment • Successful resolution - 68% @ 18 months • Mouth opening increased from 29.7 mm to 38 mm • Conclusion: Self reduction of displaced disc-unlikely • Stretching & remodelling of the retrodiscal tissues, enabling the disc to be displaced more anteriorly by the translating condyle. www.indiandentalacademy.com
  58. 58. Treatment – Disk displacement disorders • • • • • Conservative Treatment: AIMS: Reducing pain and discomfort Decreasing inflammation in muscles and joints Improving jaw function • • • • • METHODS OF CONSERVATIVE TREATMENT: 1. Patient education 2. Medication 3. Physical therapy 4. Splints www.indiandentalacademy.com
  59. 59. Treatment – Disk displacement disorders 1. PATIENT EDUCATION • Awareness about the pathology • Discontinuation of parafunctional habits • Biofeedback devices • Psychologic counseling • Modification of diet and home exercises www.indiandentalacademy.com
  60. 60. Treatment – Disk displacement disorders • • • • • • 2. MEDICAL MANAGEMENT : 1. NSAIDs 2. Muscle relaxants 3. Tricyclic antidepressants 4. Steroids 5.BOTOX www.indiandentalacademy.com
  61. 61. Treatment – Disk displacement disorders • “Treatment of severe TMJ clicking with botulinum toxin in the lateral pterygoid muscle in two cases of anterior disc displacement .” Merette Bakke, Eigild Moller et al OOOE 2005;100:693-700 • EMG guided injection BTX-A & after 6 months. • Assessment: clinical ex.,EMG, MRI • Results:Permanent elimination of clicking Small improvement in condyle - disc relationship www.indiandentalacademy.com
  62. 62. Treatment – Disk displacement disorders • • • • • • 3.PHYSICAL THERAPY 1. Isometric jaw exercises 2. Ultrasound ( 0.7 to 1.0 watts per cm 2) 3. Spray and stretch 4. Pressure massage 5. Transcutaneous Electrical Nerve Stimulation www.indiandentalacademy.com
  63. 63. 4.Splint therapy – TMJ disk displacement disorders • RATIONALE FOR THE USE OF SPLINT THERAPY • “Unloading the joint” / ↑Joint space • Reduce inflammation, increases free jaw movement • Decreases muscular activity • Provides stable dental occlusion • Possible effect in bruxism • Placebo effect www.indiandentalacademy.com
  64. 64. Types of splints • • • • • • Stabilization splint Repositioning splint Mandibular orthopedic repositioning splint Pivot splint Soft splint Bite plane splint www.indiandentalacademy.com
  65. 65. • PERMANENT OCCLUSAL MODIFICATION • Occlusal equilibration • Prosthetic restoration • Orthodontics • Orthognathic surgery www.indiandentalacademy.com
  66. 66. • “Orthodontic treatment of TMJ disc displacement with pain: an 18 year follow-up” Ugo Capurso, Ida Marini Progress in orthodontics 2007; 8(2):240-250 68 pts with wilkes II,III– splints– orthodontic Rx Tmj pain & Function – 1,5,10,18 yrs post Rx Significant % of pts.-- improvement of symptoms (73 %) www.indiandentalacademy.com
  67. 67. • “Temporomandibular joint dysfunction and orthognathic surgery: a retrospective study” Jean-Pascal Dujoncquoy, Joël Ferri et al Head & Face Medicine 2010, 6:27 • High prevalence of TMJ disorders in dysgnathic patients. • Patients with preoperative TMJ signs and symptoms can improve TMJ dysfunction and pain levels be reduced by 80 % • A percentage of dysgnathic patients who were preoperatively asymptomatic developed TMJ disorders after surgery ---3.6 % www.indiandentalacademy.com
  68. 68. Surgical treatment – Disc displacement disorders • Indications: • Patients unresponsive to conservative Rx • Wilke’s stage III,IV & V www.indiandentalacademy.com
  69. 69. Surgical treatment Options – Internal Derangement 1.Artrhrocentesis 2.Arthroscopy 3.Arthrotomy + Disc repair 4.Arthrotomy+ Disc repositioning 5.Arthrotomy+ Discectomy 6.Arthrotomy+ Discectomy+ Autologous graft 7. Alloplastic joint replacement 8. Condylotomy www.indiandentalacademy.com
  70. 70. 1.Arthrocentesis: • • • • Minimally invasive Sx procedure ↓ Local anestheisa +/- Sedation Rationale: a)Washes out inflammatory products, b) Reduces pain mediators c) releases adhesions, eliminates negative pressure d)Improves disc mobility www.indiandentalacademy.com
  71. 71. Arthrocentesis • Indications: • ID pts refractory to conservative Rx • Effective in anterior disc displacement without reduction • Technique: • Auriculotemporal nerve block • Placing Inflow & outflow needles 18/19G in superior joint cavity www.indiandentalacademy.com
  72. 72. Arthrocentesis • Irrigation with Ringer’s lactate • 1ml of hydrocotisone. www.indiandentalacademy.com
  73. 73. 2.ARTHROSCOPY • • • • • • INDICATIONS OF ARTHROSCOPY 1. Internal derangement 2. Osteoarthritis 3. Arthritides 4. Pseudotumors 5. Post-traumatic complaints www.indiandentalacademy.com
  74. 74. ARTHROSCOPY • Placement of cannula into superior joint space • Arthroscope with light source is inserted • Video camera and monitor are connected • Instrumentation forceps, scissors, sutures, medication needles, cautery probes, burs, shavers, and laser fibers www.indiandentalacademy.com
  75. 75. Arthroscopic procedures : • • • • • • • 1. Lavage 2. Lysis 3. Disk repositioning 4. Lateral capsule release 5. Synovectomy 6. Biopsy 7.Intra articular pharmacotherapy www.indiandentalacademy.com
  76. 76. Arthroscopy www.indiandentalacademy.com
  77. 77. Arthroscopy • • • • • • • • • COMPLICATIONS : 1. Vascular injury 2. Extravasation 3. Scuffing of the cartilage 4. Broken instruments 5. Otologic complications 6. Intracranial damage 7. Infection 8. Nerve injury www.indiandentalacademy.com
  78. 78. Fridrich KL et al . “Prospective comparison of arthroscopy and arthrocentesis for temporomandibular joint disorders.” J Oral Maxillofac Surg 1996; 54:816-20. • • • • • • • 19 patients GroupI: Arthroscopic lysis and lavage under general anesthesia, GroupII: Aarthrocentesis, hydraulic distention and lavage under intravenous sedation. Subjective & Objective assesment of TMJ --- 26 months Success rates : 82% - arthroscopy 75%Arthrocentesis. Conclusion: Both modalities - decreasing TMJ pain Increasing mandibular range of motion www.indiandentalacademy.com
  79. 79. Murakami K, et al. “Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage.” Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80:253-7. • 108 patients- Results of arthrocentesis, arthroscopic surgery were comparable. • Conclusion: Arthrocentesis was indicated for the patient with acute TMJ closed lock who was refractory to medication and mandibular manipulation. www.indiandentalacademy.com
  80. 80. TMJ Surgery • Surgical approaches: • Preauricular incision (Dingman’s) • Modified preauricular incisions (Thoma’s,Blair’s,Al-Kayat & Bramley’s, Popowich & Crane’s) • Endaural incision(Lamport’s) • Post auricular incision • Coronal incision • Submandibular incision(Risdon’s) • Postramal incision(Hind’s) www.indiandentalacademy.com
  81. 81. Incisions on capsule www.indiandentalacademy.com
  82. 82. 3. Arthrotomy + Disc Repair: PLICATION: • Chronic non reducing disc displacements • A wedge of retrodiscal tissue is removed • Disc is repositioned a posterior & lateral plane • The remaining retrodiscal tissue sutured directly to posterior ligament www.indiandentalacademy.com
  83. 83. 3. Arthrotomy + Disc Repair: • DISK PLICATION: www.indiandentalacademy.com
  84. 84. 4.Arthrotomy+ Disk repositioning • Condylar Diskopexy: • In Wilke’s stage –III,IV disk displacements • Displaced disk freed in both joint spacesadhesions released • Small hole drilled in Lat.pole of condyle • A 2.0/3.0 non resorbable suture passed through the hole & disk @ junction of ant. & intermediate bands www.indiandentalacademy.com
  85. 85. Condylar Diskopexy www.indiandentalacademy.com
  86. 86. Arthrotomy+ Disk repositioning • Temporal diskopexy: • In Wilke’s stage IV cases with too deformed disks • Bur holes drilled in postero-lateral lip of glenoid fossa • Disk secured to roof of fossa www.indiandentalacademy.com
  87. 87. Diskopexy- bone anchors ―Temporomandibular joint disc repositioning using bone anchors: an immediate post surgical evaluation by MRI‖ ShanYong Zhang, XiuMing Liu et al BMC Musculoskeletal Disorders 2010, 11:262 www.indiandentalacademy.com
  88. 88. 5.Arthrotomy+diskectomy • Wilkes stage IV & V , disks with perforations & severe degenerative changes • Cases with relapse of symptoms after disk repair surgeries • Fibrocartilagenous disk removed totally • Condylar / fossa irregularities smoothened www.indiandentalacademy.com
  89. 89. 6.Arthrotomy+diskectomy+autogenous graft • ―There is little evidence to suggest that autogenous graft disk raplacement is superior to no replacement at all‖ • But hypothesized rationale favouring grafting: a)graft provides scaffold for ingrowth of tissue from synovium b)May prevent degeneration that follows diskectomy. www.indiandentalacademy.com
  90. 90. Arthrotomy+diskectomy+autogenous graft • Options: • Auricular cartilage • Dermis www.indiandentalacademy.com
  91. 91. Arthrotomy+diskectomy+autogenous Flap www.indiandentalacademy.com
  92. 92. 7.Condylotomy • Popularized by Ward1952 • Creation of a displaced condylar neck # • Condyle repositons antero-inferiorly • Unloads the posterior attachment of disc www.indiandentalacademy.com
  93. 93. Hall’s Modified Condylotomy • Vertical subcondylar osteotomy • Open osteotomy procedure • More controlled approach to condylar repositioning • Less risk of total dislocation of condylar head www.indiandentalacademy.com
  94. 94. Recent advances – Rx of Internal Recent articles on Mgmt of TMJ Internal derangementRRecent derangement www.indiandentalacademy.com
  95. 95. • “Pterygoid Plate Disjunction: Minimally Invasive Treatment for Internal Derangement of the Temporomandibular Joint” Varghese Mani, Antony George et al Asian J Oral Maxillofac Surg. 2005;17:247-255 • Patients - internal derangement of TMJ, with pain and/or trismus and/or joint noise, underwent pterygoid plate disjunction on the affected side. • Subjective & Objective Assesment Pre & 18 months post-op • Results: Pain symptoms resolved in 26 of 29 joints and diminished in the remaining 3 joints. Trismus resolved in 22 of 24 patients and diminished in the remaining 2 patients. Joint noise disappeared in 23 of 30 joints • Conclusion: : Pterygomaxillary disjunction appears to be an effective treatment for painful internal derangement of the temporomandibular joint that is worthy of further investigation www.indiandentalacademy.com
  96. 96. “Pterygoid disjunction for internal derangement of Temporomandibular joint” Rohit Sharma. J.Maxillofac.Oral surg.Apr-Jun2011;10(2):142-147 • As a 1* Rx modality in Wilkes I & II in 33 pts. • Pts evaluated –Helkimo anamnestic, & clinical dysfuntion indices, pre & post opearively • All the patients had improvement in Pre operative pain & dysfunction www.indiandentalacademy.com
  97. 97. Randomized Effectiveness Study of Four Therapeutic Strategies for TMJ Closed Lock E.L. Schiffman, J.O. Look et al J Dent Res. 2007 January ; 86(1): 58–63. Comaprison of medical, rehabilitative, arthroscopy, arthroplaty. Assessment of TMJ pain & funtion @ 3,6,12,18,24,60 months • Within-group improvement for all groups • Conlusion: Primary treatment for individuals with TMJ closed lock should consist of medical management or rehabilitation. • This approach will avoid unnecessary surgical procedures. www.indiandentalacademy.com
  98. 98. Chronic Recurrent dislocation of Condyle • Recurrent dislocation of condyle out of the fossa & anterior to eminece. • Predisposing factors: • Laxity of the ligaments • Degenerative joint disease • Morphologic condition of condyle & eminence • Non synchronised muscle function www.indiandentalacademy.com
  99. 99. Chronic Recurrent dislocation of Condyle- TREATMENT • • • • • • Miller & Murphy (1976)*: 1.Capsular tightening procedures 2.Creation of a mechanical obstacle 3.Direct restraint of condyle 4. Creation of new muscle balance 5.Removal of mechanical obstacle www.indiandentalacademy.com *-Viva Q / Short Q/ Essay Q
  100. 100. Chronic Recurrent dislocation of Condyle- TREATMENT contd… • 1.Capsular tightening procedures: • Chemical sclerosants: Sod.teradecyl sulfate,etc • Capsulorrhaphy: • Placement of horizontal mattress sutures • Placement of vertical incision, overlapping edges & suturing www.indiandentalacademy.com
  101. 101. Chronic Recurrent dislocation of Condyle- TREATMENT contd… • 2.Creation of mechanical obstacle: • A)Eminence augmentation • i)Schadeeminence osteotomy & silastic block sandwich & wiring • ii)Glenotemporal osteotomy www.indiandentalacademy.com
  102. 102. Chronic Recurrent dislocation of Condyle- TREATMENT contd… • iii)Gossarez & Dautry: • iV)Findlay: L shaped pins www.indiandentalacademy.com
  103. 103. Chronic Recurrent dislocation of Condyle- TREATMENT contd… • 3.Direct restraint of condyle: • Gordon– Fascia lata, sutured between condyle & zygomatic arch • Wire • Temporal fascia www.indiandentalacademy.com
  104. 104. Chronic Recurrent dislocation of Condyle- TREATMENT contd… • 4.Creation of new muscle balance: • Ward’s condylotomy • Gould- stripping temporalis tendon to limit anterior excursions of condyle • Laskin- Lateral pterygoid musc.detachment www.indiandentalacademy.com
  105. 105. Chronic Recurrent dislocation of Condyle- TREATMENT contd… • 5.Removal of mechanical obstacles: • A)Annandale 1887--- Discectomy • B)Myrhaug 1951--- Eminectomy • www.indiandentalacademy.com
  106. 106. Chronic Recurrent dislocation of Condyle- TREATMENT contd… C) Condylectomy: www.indiandentalacademy.com
  107. 107. Recent articles – TMJ dislocation ―Evaluation of the mechanism and principles of management of temporomandibular jointdislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation‖ --- Babatunde O Akinbami -Head & Face Medicine 2011, 7:10 www.indiandentalacademy.com
  108. 108. Key to success ---PG Exams • • • • • • A B C D E F - Articles / Authors Books Charts/flowcharts/algorithms.. Diagrams Estimate time Format Your answers www.indiandentalacademy.com
  109. 109. Suggested Reading: • • • • Peter.D.Quinn: Atlas of TMJ surgery Irby:Volume -3 TMJ Disorders Norman & Bramley- TMJ Disorders Fonseca, Vol-4 of seven volume series: TMJ disorders • OMS clin. North america. –Modern surgical management of the TMJ –Vol.18,No.3,aug.2006 • Okeson: Orofacial Pain www.indiandentalacademy.com
  110. 110. Thank YOU www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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