Temporomandibular joint disorders of the jaw, different pathologies related to TMJ

1. 1

2. OUTLINESS
 Anatomy of the temporomandibular joint
 Temporomandibular Joint Disorders Classification
 Surgical Approaches to Mandibular Condyle and Its
Neck
2

3. Anatomy
►Also known as craniomandibular joint
►Articulate between squamous part of temporal bone
and head of mandibular condyle
►Diarthroidal or freely movable joint
3

4. CONT.
►TMJ articulation consists of :
 Mandibular or Glenoid fossa
 Articular eminance
 Condyle
 Separating disc
 Joint fibrous capsule
 Extra capsular check ligament
4

5. Mandibular fossa
►Limits: Ant.:- Articular eminance
Post.:- Postglenoid tubercle
►Articular area is formed by inferior aspect of
squamous part of temporal bone.
►Fossa is lined by a dense avascular fibro-cartilage
5

6. 6

7. 7

8. Articular Eminance
►Small prominance on zygomatic arch
8

9. Condyle
►Dimension: Mediolaterally- 13-25mm
Anteroposteriorly- 5.5-16mm
►Articular part of condyle is covered by
fibrocartilaginous tissue and not hyaline cartilage.
9

10. Separating disc
►The meniscus or articular disc or separating disc
divides articular space into 2 compartments
 Lower/Inferior compartment:- between condyle and
disc(condylodiskal complex)
 Upper/superior compartment:- between disc and
glenoid fossa(temporodiskal)
10

11. Cont.
►Disc blends medially and laterally with capsule
►Posteriorly disc is attached to glenoid fossa above and
to neck of condyle below. This area is called posterior
bilaminar zone or retro discoidal tissue which has a
rich neurovasular supply. Sensory branch of
auriculotemporal nerve is abundant here.
11

12. Cont.
►Vol. of upper joint space- 1.2 ml
Lower joint space- 0.9ml
►Disc has 3 zones
►Anterior band. - 2mm thick
►Posterior band- 3mm
►Intermediate zone - 1mm
12

13. 13

14. 14

15. Cont.
►Functions of separating disc
1. Promotes lubrication
2. Promotes energy absorption
3. Promotes range of motion
4. Act as shock absorber
15

16. Joint capsule
►Funnel shaped
►Attached above-
• Ant.: Articular eminence
• Post.: Squamotympanic fissure
• Below.: Neck of condyle
►Lined by synovial membrane which
create synovial fluid
16

17. Cont.
►Synovial fluid is:- Ultrafiltrate of
blood plasma + Mucin
 Composed of hyaluronic acid
 Function:-
 Nutrition
 Phagocytosis
17

18. Ligaments:
►Lateral or Temperomandibular ligament
 TMJ Capsule is reinforced by this
 Extends from articular eminance to condylar neck
 Limits ANT. Excursion and prevents post. dislocation-
Hence called as check ligaments
►Accessory ligaments
 Stylomandibular
 sphenomandibular
18

19. 19

20. Blood Supply
►Arterial supply:
 Superficial temporal artery,
 post. Auricular a.
 branch of maxillary artery
 Deep auricular a.
 massetric a.
►Venous drainage:
 venous plexus around capsule
20

21. 21

22. Nerve Supply
►Mandibular nerve:
Auriculotemperal branch-sensory
Masseteric branch-motor
Post. deep temporal branch -motor
22

23. Movements
► Jaw opening(Depression):-
 Digastric, sternohyoid, geniohyold, lateral
pterygoid muscle
► Jaw closure (Elevation):
 Masseter, temporalis, medial pterygoid
► Protrusion:
 Medial and lateral pterygoid
23

24. Cont.
►Retrusion:
 Temporalis, masseter, digastric,
geniohyoid
►Lateral Excursion:
 Medial and lateral pterigoid
24

25. TMJ disorders
►2 types: Intracapsular and Extracapsular disorders
I. Intracapsular disorders
1. Trauma
► Dislocation
► Subluxation
► Haemarthrosis
► Intracapsular #
25

26. Cont.
2. Internal disc displacement
• ANT. Disc displacement with reduction
• ANT. Disc " with out reduction
3. Arthritis
• Osteoarthritis
• Rheumatoid arthritis
• Juvenile rheumatoid arthritis
• Infectious arthritis
26

27. Cont.
4. Developmental Defect
• Condylar agenesis
• Bifid condyle
• Condylar hypoplasia
• Condylar hyperplasia
5. Ankylosis
27

28. Cont.
6. Neoplasm
 Benign:- Osteoma, Osteochondroma, Chondroma
 Malignant:- Chondrosarcoma, synovial sarcoma,
fibrosarcoma
28

29. Cont.
II. Extracapsular Disorders
1. Mastcatory muscle disorders
► Masticatory muscle spasm (MPDS)
► Masticatory muscle inflammation (myositis)
2. Disorder due to extrinsic trauma
► Traumatic arthritis
► Fracture
► Internal disc derangement
► Myositis, myospasm
► Tendonitis
29

30. PATIENTEVALUATION-History
-Examination
A. EXTRAORALLY
1.Symmetry
2.Deviation
3.Muscular hypertrophy
4.Masticatory muscles palpation
5.TMJ examination
Tenderness
Sounds
Range of movement (II-45mm,LE-10mm)
30

31. B-INTRA ORALLY
 Odontogenic source of pain
 Wear facets
 Mobility
 Soreness
 Dental & skeletal classification (Occlusion)
31

32. INTRAAURICULER EXAM.
32

33. PREAURICULER EXAM
33

34. MASSETER EXAM
34

35. TEMPORALIS EXAM.
35

36. Radiographic evaluation
 1.panoramic radiography
 2.tomograms
 3. transcranial
 4.TMJ arthrography
 5.MRI
 6.nuclear imaging
Psychological evaluation
36

37. Intracapsular disorders
Dislocation, subluxation,
hypermobility
►Excursion of condylar head beyond anterior slope of
articular eminence is termed as dislocation.
►Dislocation-Unilateral or bilateral
►Dislocation-A/C, C/C recurrent subluxation, long
standing
►A/C dislocation-known as luxation
37

38. Cont.
►Incomplete dislocation- known as subluxation,
hypermobility, c/c recurrent habitual dislocation
38

39. 39

40. A/c dislocation
►Causes of A/c dislocation
• Extrinsic or Latrogenic causes
• Intrinsic causes
1. Extrinsic causes
• Blow on chin while mouth is open
• Injudicious use of mouth gag during GA
• Excessive pressure on mandible during dental extraction
40

41. Cont.
►2. Intrinsic or self induced causes
• Excessive yawning
• Vomiting
• Singing loudly
• Blowing wind instruments
• Laughing loudly
• Opening mouth too wide for eating
• Hysterical fits
41

42. Cont.
►Predisposing factors:
 Laxity of ligaments capsule
 Abnormality of skeletal form
 Previous injuries
 Occlusal disharmonies
 Flattened eminance
 Shallow fossa
 Parkinson's disease, epilepsy, ehler's danlos syndrome
42

43. Cont.
►Clinical Features
• Unilateral or bilateral
• Unilateral:
► Difficulty in mastication and swallowing and speech with
profuse drooling of saliva
► Deviation chin towards contralateral side
► Lateral cross bite and open bite on contralateral side
► Mouth is partly open
► Affected condyle cannot be palpated
► Depression in front of tragus.
43

44. Cont.
►Bilateral
• Pain in temporal region
• Inability to close mouth
• Tenderness of masticator muscles
• Difficulty in speech, swallowing
• Excessive salivation
• Protruding chin
• Mandibular movements restricted
• Gagging of molar teeth
• Anterior openbite
• Hollowness in both preauricular regions
• Muscle spasm
44

45. 45

46. Cont.
►Management
• Reduce tension, anxiety & muscle spasm by:
► reassuring the patient
► Tranqulizers and sedatives
► Pressure and massage to the area
► Manipulation by 3 ways
• Manipulation with out any form of anaesthesia
• " with LA
• " Under GA & sedation with muscle
relaxants.
46

47. Cont.
►Manipulation procedure
• Patient should be given assurance and asked to relax
completely
• LA is injected into glenoid fossa. This will eliminate pain
and spontaneous reduction
• Stand in front of patient and grasp mandible with both
hands. Thumbs are covered with guaze. As sudden
reduction can trap the thumbs. Thumbs are placed on
occlusal surface of lower molars and finger tips are
placed below chin. Exert downward pressure on
posterior teeth to depress jaw and at the same time
upward and backward pressure with fingertips
47

48. Cont.
 Ask the patient to keep oral opening restricted.
 Immobilization by barrel bandage for 10-14
days.
 Semisolid diet
 Avoid excessive oral opening, support chin
while yawning
 NSAID -- for - 3- 5 days
48

49. Cont.
►Long standing dislocation. Dislocation for more than
one month
 Reduction is done under GA
 If manual reduction fails surgery
 Open joint through preauricular incision, manipulation
by direct vision, if fails,
 eminectiomy or condylectomy
49

50. Chronic recurrent or habitual
dislocation or subluxation
►It is the repeated episodes of dislocation where there is
abnormal anterior excursion of condyle beyond
articcular eminence, but patient is able to manipulate
back into normal position.
►Predisposing factors
 Ligmentous and capsular flaccidity
 Eminential erosion and flattening trauma
50

51. Cont.
►In these individuals yawning, vomiting, laughing may
precipitate subluxation.
►It is also seen in severe epilepsy, ehlers-danlos
sxndrome, teachers ,speakers, mucisians.
►C/C subluxation with pain:- in some patients, sudden
sharp and severe pain occurs when mouth is opened
widely.
51

52. Cont.
►Management:
 Intermaxillary fixation or limiting oral opening by
elastics
 Total immobilization of jaw for 3-4 weeks and
patient is kept on liquid diet
 Use of sclerosing solution injection into joint
space:- Na tetradecyl sulphate - It brings about
fibrosis of capsule of but is short lived.
52

53. Cont.
 Surgical Procedures:
► A. Capsule tightening procedures
 Capsulorrhaphy:- shortening capsule by removing a
section and suturing to make it tight.
 Placement of vertical incision in capsule and
drawing it tight by overlapping the edges and
suturing.
 Reinforcement of joint capsule:- By turning down a
strip of temporal fascia and suturing to capsule
53

54. Cont.
► B. Creating a mechanical obstacle
 Osteotomy on eminence and turn it down in
front of condylar head to prevent the
condylar movement forward.
 Placement of a graft from zygoma over
eminence to increase size and Height.
 Placement of implants (Vitallium mesh) to
Add height to eminence.
 Osteotomy on zygomatic arch & depressing it
in front of condylar head to serve as obstacle to
forward movement.
 L-shaped pins anchores in zygomatic process
of temporal bone & projecting it ant to condyle
54

55. Cont.
► C. Direct Restrain of Condyle
 Temporalis fascia turned down and sutured to
lateral surface of articular capsule
 Piece of fascia lata threaded through a hole in
zygomatic arch and second hole in condyle. Fascia is
tightened.
55

56. Cont.
►D. Removal of mechanical obstacle
 Removal of torn meniscus or meniscectomy but it
causes pain, roughening condylar head,
occasional ankylosis.
 High condylectomy:- Head of condyle shortened,
so less tendency to lock in front of articular
eminence.
 Excision of condylar head above attachment of
lateral pterygoid muscle.
 Eminectomy:- It allows condylar head to move
forward and backward free of obstacle, by the
excision of articular eminence.
56

57. Eminectomy
► Indications
• Recurrent dislocations
• C/c hyrermobility associated with severe pain
• Irreversible TMJ pain associated with clicking or
grating.
► Advantage
• Main joint cavity is not opened up and avoid injury
to meniscus and capsule
• Can be performed under LA.
57

58. Cont.
►Procedure:
• Small horizontal incision is made over zygomatic arch in
the region of articular eminence in front of tragus.
• Articular eminence is located 1.5cm ant. to external
auditory meatus.
• Distance is measures and location of eminence is
marked with ink prior to incision.
• Eminence is exposed by a T-incision. Horizontal over
the arch and vertical extending to apex of eminence.
58

59. Cont.
 Periosteum is reflected until lateral part is exposed.
 A series of bur holes are made at the base of eminence.
 Extend the cut inward.
 Eminence is cut and separated with osteotome
 Smoothened with bone file
 Irrigate and sutured
 Pressure dressing for 48-72 HRS.
59

60. Eminectomy
60

61. Internal derangement of TMJ
►Def:-it is the disruption of internal aspects of tmj,
in which an abnormal relationship exists b/w the
disc & condyle, fossa &articular eminance.
►Associated changes:-
• Synovitis
• Intracapsular adhesions & scarring
• Haemorrage
• Dystrophic calcifications
• Osteoarthritis
61

62. Cont.
►Etiology:-
 Microtrauma:-
► Bruxism
► Parafunctional habits
► Hypermobility of joint
 Macrotrauma:-
► H/o trauma
62

63. Cont.
►Symptoms:-
 Pain during function
 Limited oral opening
 Masticatory & cervical tenderness.
63

64. Anterior disc displacement with
reduction
►Disc is dislocated anterior to the condylar head.
►There is pain during translation
►Patient has a click on opening as the posterior part of
the disc interferes with condylar translation.
►A click less noticeable on closing as the condyle
returns to the original position.
64

65. 65

66. Radiographic feature
 - Plain x-ray may be normal
 - MRI shows Ant. displacement of disk
66

67. Management
Reassurance and explanation
Occlusal splints, ant. repositioning splint
Physiotherapy
NSAIDS
67

68. Anterior disc displacement
without reduction
►The patient cannot open mouth fully.
►If patient attempts to open mouth there will be pain in
affected joint & deviation of mandible towards the
painful side,no click.
►It is a unilateral condition
68

69. 69

70.  R/F:
plain x-ray may be normal or there is signs of
osteoarthrosis
MRI…abnormal disc position
 Management
 reassurance, explanation
 muscle relaxant and physiotherapy
 Analgesics
 manipulation under anesthetic
 arthrocenesis
 menisectomy and disc replacement 70

71. DEVELOPMENTAL DEFECTS
Condylar agenesis or aplasia
►Unilateral agenesis cause facial asymmetry &
deviation of mandible to the affected side during
opening.
►Treated by rib grafts.
71

72. Condylar hypoplasia
►May be congenital or acquired.
►Acquired may be due to:-
 Birth injuries
 Trauma
 Radiation
 Local extension of infection
72

73. Condylar hyperplasia
►It is usually unilateral.
►The chin is deviated away from the affected side.
►It is not usually associated with pain.
►Treated by surgical resection of condyle.
73

74. Fracture
►Fracture of neck of condyle usually follows trauma
to chin.
►It may be unilateral or bilateral.
►There will be pain & edema in the joint area.
►There is limitation of mouth opening or deviation
of mandible to the painful side during opening.
►Bilateral condylar fracture causes anterior open
bite.
74

75. DEGENERATIVE JOINT DISEASES (DJD)
(OSTEOARTHROSIS, OSTEOARTHRITIS
 Definition:- variety of anatomic findings including
irregular ,perforated or severely damaged discs in
association with articular surface abnormalities i.e..
Flattening, erosion, lipping…….
75

76. Direct mechanical trauma: excessive mechanical
loading ----free radicals----intracellular damage.
 Hypoxia perfusion theory: excessive intracapsular
hydrostatic pressure within the TMJ may exceed the
blood level---hypoxia
 Neurogenic inflammation:- stretching of nerve-
rich retrodiscal tissue----cytokines
Osteoarthritis differ from osteoarthrosis in
2ry inflammation
76

77.  C/F:
 elderly most affected
 pain
 crepitus
 tender joint
 limitation of mouth opening
 Course of the disease
 Painful inflammatory, erosive phase, lasts for 3yrs.
 Phase of resolution---- smooth out again
 R/F
 Bony changes: erosive, lipping, anvil shape deformity
,Ely’s cyst , irregularity in condylar head.
77

78. Effusion
 Influx of fluid into the joint, usually either bleeding
following trauma or inflammatory exudates.
 C/F:
 pain & swelling over joint
 limitation of movement
 sensation of blocked ear
 difficulty in occluding posterior teeth
 R/F: widened joint space
 Management:
 Anti-inflammatory drugs
 Rarely surgical drainage
78

79. Rheumatoid arthritis
vasculitis of synovial membrane
↓
c/c inflammation
↓
granular tissue formation
↓
erosion of bone
79

80. CONT.
►Symptoms
• Bilateral involvement
• Restricted mouth opening
• Joint pain
• Morning stiffness
• Joint sounds
• Tenderness
• Swelling
• Crepitus
80

81. CONT.
►Radiographic findings
• Erosion of condyle & glenoid fossa
►Treatment:-
• Antiinflammatory drugs
• Soft diet
• Jaw exercises
• Intraarticular steroids
81

82. Trismus
►It is the restriction of oral opening
►Causes:-
 Infection:-
► Pericoronitis
► Ludwig`s angina
► Submasseteric abscess
► Infratemporal abscess
► Tb osteomyelitis
82

83. Cont.
• Trauma:-
►# of zygomatic arch
►# of mandible
• Inflammation:-
►Myositis
• Myositis ossificans
• Tetany:-due to hypocalcemia.
83

84. Cont.
• Mechanical blockade
► Elongation, exostosis, osteoma, osteochondroma of coronoid
process.
► Extra articular fibrosis
► Ossification of sphenomandibular ligament.
• Bleeding produced by needle puncture in medial
pterigoid muscle.
►
84

85. Surgical approach to the TMJ
85
1.Preauricular incision
2.Temporal extension
3.Question mark extension
4.Submandibular incision
5.Endaural approach

86. Pre auricular surgical approach to
TMJ
►Preparation of surgical site:-
 Draping should expose entire ear & lateral canthus of
eye
 Shaving of pre auricular area is done.
 Cotton soaked in antibiotic ointment is placed into
external auditory canal.
►Marking of incision:- incision is outlined at the
junction of facial skin with helix of ear.
86

87. CONT.
►Infiltration of vaso constrictor:-vasoconstrictor is
injected subcutaneously in the area of incision to
decrease bleeding.
►Skin incision:-incision is made through the skin,
subcutaneous tissue to the superficial layer of
temporalis fascia
►Dissection of TMJ capsule:-
 the flap is retracted anteriorly.
87

88. CONT.
► An oblique incision is made through the temporalis fascia from
the root of zygomatic arch to the upper corner of retracted flap.
 expose the lateral aspect of zygomatic arch till the
articular eminence is exposed.
 The tmj capsule is then seen
 Inverted L-shaped incision is given in the capsule &
retract the flap.
 cut along the lateral aspect of eminance & fossa
88

89. CONT.
 A vertical incision is made in the capsule till the
condylar neck.
►Wound closure
 Joint space is irrigated well
 Haemorrhage is controlled
 Wound is closed in layers
89

90. ANKYLOSIS OF TMJ
►ANKYLOSIS A GREEK WORD MEANS STIFF JOINT.
90

91. CLASSIFICATION
►False ankylosis & True ankylosis
►Extra-articular ankylosis & Intraarticular
ankylosis
►Fibrous ankylosis & Bony ankylosis
►Unilateral ankylosis & Bilateral ankylosis
►Partial ankylosis & Complete ankylosis
91

92. Etiology
1. Trauma
• At birth –forceps delivery
• Hemarthrosis
• Condylar fracture
• Glenoid fossa fracture
92

93. Cont.
2. Infections
• Otitis media
• Parotitis
• Tonsilitis
• Furuncle
• Abscess around joint
• Osteomyelitis of jaw
• Actinomycosis
93

94. Cont…
3. Inflammation
• Rheumatoid arthritis
• Osteoarthritis
• Septic arthritis
94

95. Cont.
4. Rare causes
• Polyarthritis
• Measles
5. Systemic diseases
• Small pox
• Scarlet fever
• Typhoid
• Beriberi
95

96. Cont.
6. Other causes
• Bifid condyle
• Prolonged trismus
• Prolonged immobilization
96

97. Clinical manifestations
►Early joint involvement:-
 <15 years
 severe facial deformity & loss of function
► Later joint involvement:-
 after 15 years
 less facial deformity & severe functional loss.
97

98. CONT.
►Unilateral ankylosis
• Seen in children or in person where the onset was in
childhood
• Obvious facial asymmetry.
• Deviation of mandible & chin to affected side
• Chin is receded with hypoplastic mandible on the
affected side.
• Roundness & fullness of face on affected side
• Flatness & elongation on unaffected side.
98

99. CONT.
 Lower border of mandible on the affected
side has a concavity that causes a well defined
antegonial notch.
 Some amount of oral opening may be
possible.
 Cross bite may be seen.
 Angles class 2 malocclusion on affected side
& unilateral crossbite
 Condylar movements are absent on the
affected side.
99

100. 100

101. Cont.
►Bilateral ankylosis
 Mandible is symmetrical but micrognathic.
 Bird face deformity with receding chin
 Antegonial notch is well defined bilaterally
 Angles class 2 malocclusion
 Protrusive upper incisors
 Anterior openbite
 Oral opening less than 5 mm or many times there is nil oral
opening.
101

102. Cont.
 Multiple carious teeth with poor periodontal health.
 Crowding of teeth
 Presence of impacted teeth
102

103. 103

104. Diagnosis
►Orthopantomograph:- presence of
antegonial notch can be detected.
►Lateral oblique view:- gives anteroposterior
dimension of condylar mass and elongation of
coronoid process can be seen.
►Posteroanterior radiograph:- highlight
asymmetry in unilateral cases.
104

105. Radiographic findings
►Fibrous ankylosis :-
• reduced joint space
• hazy appearance
• normal anatomy can be appreciated
►Bony ankylosis:-
• complete obliteration of joint space.
• deformed condylar head
• elongation of coronoid process
105

106. Grading of ankylosis
►Type 1:-
 condylar head is present without much
distortion.
 fibrous adhesion make the movement
impossible
► Type 2:-
 bony fusion of misshaped head & articular
surface.
 no involvement of sigmoid notch & coronoid
process.
106

107. CONT.
►Type 3:-
• a bony block bridging across the ramus & zygomatic
arch
• medially an atrophic, dislocated fragment of former
head of condyle is found
• elongation of coronoid process is seen
►Type 4:-
• normal anatomy of TMJ is totally destroyed
• complete bony block b/w ramus & skull base.
107

108. Sequelae of untreated ankylosis
►Normal facial growth & development are
affected
►Speech impairment
►Nutritional impairment
►Respiratory distress in bilateral involvement
►Malocclusion
►Poor oral hygiene
►Multiple carious & impacted teeth.
108

109. Management
1. Condylectomy:-
• Indication:- fibrous ankylosis in which there is no
much deformity of condyle.
• Procedure:
► Preauricular incision
► Horizontal oseotomy cut at the level of condylar
neck
► Vital structures on medial aspect are protected by
the condyle retractor
► Condylar head is separated
► Rough bone is smoothed
► Wound is closed in layers.
109

110. CONT.
2. Gap arthroplasty:-
• Indication:- bony ankylosis, thick area of bone
obliterates entire joint, sigmoid notch & coronoid
process
• procedure:-
 After the incision, 2 horizontal osteotomy cuts are made
 Bone is removed until a thin medial bone is left.
 Thin medial bone is removed with a chisel or osteotome.
 A gap of at least 1 cm is created.
110

111. 111

112. Cont.
3. Interpositional arthroplasty
 Involves creation of a gap & insertion of a barrier b/w the cut
bony surfaces to minimize recurrence.
 Inter positional materials used:-
a. Autogenous
 Cartilagenous
► costochondral
► Metatarsal
► Sternoclavicular
112

113. Cont.
• Temporal muscle
• Temporal fascia
b. Heterogenous
• Chromatized submucosa of pig bladder.
• bovine cartilage
c. Alloplasts
• Metallic
► tantalum foil/plate
► stainless steel
► Titanium
► gold
113

114. Cont.
 Nonmetallic
►Silastic
►Teflon
►Acrylic
►Nylon
►ceramic
114

115. 115

116. Cont.
4. Interposition arthroplasty using autogenous
costochondral graft
• Costochondral graft is obtained by inframammary
incision
• 5th, 6th or 7th rib is taken.
• If 2 ribs are required intervening rib is left
• A min. Of 1.5 cm of costochondral junction should be
included
• It should be carved to simulate condylar head.
• The graft is fixed on the lateral aspect of ramus with
screws.
• A min. Gap of 0.5 to 1cm should be kept b/w graft &
glenoid fossa.
116

117. 117

118. Cont.
5. Artificial replacement of joint
• Prefabricated condylar prosthesis made of steel or
vitallium can be used.
• Prosthesis may be commercially available or custom
fabricated
118

119. Complications during TMJ
ankylosis surgery
►During anesthesia:-
• Because of small mandible & difficulty in opening
mouth, intubation poses a problem.
• Aspiration of blood clot, tooth or foreign body as
throat cannot be packed prior to surgery
►During surgery:-
• Hemorrhage due to damage to superficial temporal
vessels, transverse facial artery, inferior alveolar
vessels, internal maxillary vessels, pterigoid plexus of
veins.
119

120. CONT.
 Damage to external auditory meatus.
 Damage to zygomatic & temporal branch of facial nerve
 Damage to glenoid fossa
 Damage to auriculo temporal nerve.
 Damage to parotid gland
 Damage to teeth
120

121. CONT.
►Post operative:-
• Infection
• Open bite
• Recurrence of ankylosis
• Frey`s syndrome
►frey`s syndrome
• First described by frey.
• Also known as auriculo temtoral nerve
syndrome
• Usually follows surgery of parotid gland &
TMJ, parotid abscess drainage
121

122. CONT.
►clinical features:-
 Pain in auriculotemporal nerve distribution.
 Associated gustatory sweating & erythema
 Flushing on the affected side of face, associated
sweating in periauricular region & beneath the pinna.
122

123. CONT.
►Treatment:-
• Topical glycopyrrolate- anticholinergic
• Radiation therapy
• Skin excision:- if only a small area is affected.
• Auriculotemporal nerve section
123

124. Recurrence
►Causes:-
 Inadequate gap b/w fragments.
 Fracture of costochondral graft.
 Loosening of costochondral graft
 Inadequate post operative physiotherapy
124

125. 125

126. Introduction
►MPDS is a pain disorder in which unilateral pain is
referred from trigger points in myofacial structures to
the muscles of head & neck
►Pain is constant, dull ache, it may range from mild to
intolerable.
126

127. Etiology
1. Psychogenic cause:-
• Psychologically unbalanced individuals, due to unusual
habits, there will be muscle disturbance, causing
occlusal disharmony leading to tmj disorder.
• Under emotional stress, skeletal musculature exhibits
hyperfunction, leading to muscle contraction & muscle
fatigue.
127

128. Cont.
2. Oral habits:-
 Pipe smoking.
 Sleeping on stomach with mandible supported by
forearm,
 Teeth clenching,
 Teeth grinding,
 Lip licking,
128

129. Cont.
 Jaw thrusting,
 Nail biting,
 Tongue thrusting,
 Pencil/pen biting,
 Constant chewing of tobacco, gum
129

130. Cont.
3. Occlusal disharmony:-
 Inherent malocclusion; developmental deformity
 Acquired malocclusion; failure to replace any lost
teeth for prolonged period causes drifting of teeth
causing occlusal imbalance.
 Iatrogenic occlusal disharmony; faulty
restoration with high points, unbalanced vertical
dimension in dentures.
130

131. Pathophysiology
►Muscle injury causes increased tone of musculature
which leads to muscle fatigue & accumulation of
metabolic byproducts causing pain.
131

132. Signs & Symptoms
►Pain or discomfort anywhere in head & neck
region.
►Limitation of motion of jaw. normal vertical range
of motion is 40 to 50 mm. normal lateral range of
motion is 10mm. normal range of protrusive
movement is 10mm.
►Joint noises-clicking.
►Tenderness to palpation of the muscles of
mastication .
132

133. Associated musculoskeletal
symptoms
►Tension
►Joint pains
►Tiredness
►Weakness
133

134. Treatment
►Elimination of the cause :-
• Occlusal discrepancies
• Stress:– counselling the patient
►Auriculotemporal nerve block:-
• A 26 or 27 gauge needle is inserted through the skin
just anterior to the junction of tragus & ear lobe.
• Needle is advanced to a depth of 1cm & 1.5 ml of
anesthetic solution is deposited.
• Pain is eliminated or decreased in 5 min.
134

135. Cont.
►Medications
 NSAID - to reduce inflammation and to provide
pain relief, both in the muscles as well as in the
joints. For 14 to 21 days .
 Aspirin 2 tabs 0.3 to 0.6 gm/ 4 hourly or
 Piroxicam 10 to 20 mg / 3-4 times a day or
 Ibuprofen 200 to 600mg / 3times a day
135

136. Cont.
 Muscle relaxants - are recommended only for short
duration, as they produce sedation and addiction .
► Diazepam 2 to 5 mg bed time can be given 10 days.
 Intramuscular local anesthetic injections in the
affected muscles can also give relief .
136

137. Cont.
►Physiotherapy -
 Heat application:- increases local circulation
 Moist or dry heating pads, hot moist application
of towels can be given for 15 to 20 min. 4 times a
day.
►Cryotherapy:-
 Ice pack application to the painful area 4 times a
day for 20 min. it lowers pain by counter -
irritation
137

138. Cont.
 Use of vapocoolant spray:- flouromethane
or ethyl chloride spray is applied for 5 sec.
 Electrogalvanic stimulation:- stimulates
local circulation
 Transcutaneous electronic nerve
stimulation:- increaese blood flow to the site
& interferes with pain sensation.
138

139. Cont.
• Active stretch exercises:- opening & closing
mouth for 10 times
►Stress management:-
• Acupuncture
• Yoga
• Hypnosis
• Meditation
• Deep breathing relaxation
139

140. 140

141. Cont.
►Intra articular injections:-
 2% lignocaine with hydrocortisone is injected once
in a month to relieve pain & inflammation.
 The patient`s mouth is kept open wide with a
mouth prop.
 1ml solution is injected with a 25 guage 1.5`` long
needle.
 Needle is directed inward, forward & upward until it
strikes the roof of glenoid fossa at a depth of 2 to
3cm.
141

142. Cont.
• Needle is withdrawn 5mm & 1 ml solution is injected after
aspiration.
• After changing the direction downward rest of solution is
injected into lower joint space.
• Patient should be covered with antibiotics & anti-
inflammatory drugs.
►Occlusal splints:-
• 12 to 18 hrs use for 4 to 6 months.
• Fabricated in acrylic over maxillary teeth covering the
incisal & occlusal surfaces.
142

143. Cont.
 A plat form is created perpendicular to lower incisors
,so the splint will disengage teeth & relax muscles.
 It eliminates occlusal discrepancies.
►TMJ arthrocentesis:-
 objectives:-
 Improve disc mobility.
 Eliminate joint inflammation
 Eliminate pain.
143

144. Cont.
• technique:-
• Patient`s mouth is fully stretched open.
• 2 points are marked in the pre auricular
area indicating articular fossa & eminance.
• Auriculotemporal nerve block injection is given.
• 19 or 18 guage needle is inserted into the upper joint
space upto a depth of inch.
• Another 19 or 18 guage 15 inch needle is inserted at
the second mark corresponding to articular
eminance.
144

145. 145

146. Cont.
 10cc syringe is filled with ringer lactate solution &
connected to the first needle.
 Solution pushed to distend the joint space.
 Solution will come out through the second needle.
 Upto 200 ml solution is pushed until clear fluid comes
out through the second needle.
 1 ml hydrocortisone is injected before removing the
needle.
146

147. Cont.
• post arthrocentesis medication:-
• Naproxen sodium 275 mg 3 times daily
• Diazepam 2.5 to 5 mg at bed time for 2 weeks.
• Patient kept on soft diet.
• Procedure is repeated after 1 week at least for 3 or 4
weeks.
►Surgical treatment:-
• Condylar shave & arthroplasty:-remove several mm
of articular surface & recontouring.
147

148. Cont.
 Condylectomy:-excision of condyle
 Eminectomy-removal of anterior eminance
148

149. References
149
PETERSON'S
PRINCIPLES OF
ORAL AND
MAXILLOFACIAL
SURGERY
Second Edition
www.allislam.