This is a presentation on the clinical features of Tmj dislocation

1. BDS/10/18
UNDISA EURO

2. TMJ DISLOCATION
• Subluxation(hypermobility)-An overextension of the
disc condyle complex on opening beyond the
eminence
• Joint dislocation-A dislocation of the entire disc
condyle complex beyond the eminence combined
with the inability to return passively into the fossa

3. Epidemiology
• Uncommon compared to other dislocations
• 3%incidence
• Uncommon in extremes of age
• Higher incidence in females
• Most commonly occurs in anterior direction in
relationship with the articular eminence
• Superior,posterior and adjacent medial dislocations are
associated with fracture of mandible

4. Causes
• Iatrogenic-Intubation, dental procedures endoscopy
• Traumatic-High energy trauma causing fractures of
boundaries of joint space such as the glenoid fossa
• Systemic disease-Ligamentous laxity such as Ehlers
Danlos,marfan,muscle dystonia.
• Medications- Antipsychotics,phenothiazines
• Spontaneous-Yawning, taking large bites,laughing
,singing,vomiting

5. Classification
• Unilateral or bilateral
• Acute or chronic
Chronic-long standing
recurrent
habitual
• Based on the position of the head of the condyle to the
articular eminence as seen on clinico-radiological evaluation;
Type I –the head of the condyle is directly below the tip of the
eminence
Type II-the head of condyle is in front of the tip of the eminence
Type III-the head of the condyle is high up in front of the base of
the eminence

8. Clinical presentation
Bilateral dislocation
• Pain
• Inability to close mouth
• Tense masticatory muscles
• Difficulty with speech
• Excessive salivation
• A protruding chin
• Open bite
• A distinct hollow in front of the tragus
• The lateral pole of the condyle produces a protuberance anterior
and below the eminence.
• Coronoid process may create prominence below the zygoma
• Pain in temporal fossa rather than the joint.

9. Unilateral dislocation
• The mandible swung away from the side of dislocation
• The deviation produces lateral gross and open bite on contralateral side
• Occlusion is protrusive
• The hollow just in front of the tragus is present on the ipsilateral side

10. Diagnosis
 History
• A prior history of local joint laxity, ID and other TMJD
• Determine cause and onset
• Use of antipsychotic drugs
 Physical exam
• Neurological and musculoskeletal disorders
 Radiological examination-MRI

11. Goals of treatment
• Restrict mandibular translation
• Remove obstacles
Treatment
• Non-surgical treatment
• Medications-NSAIDS, muscle relaxants, steroids
• Digital manipulation
• Psychological management
• Physical therapy-Isometric exercises
• Occlusal therapy-correction of occlusal interference ,restoring
vertical support of occlusion
• Intermaxillary fixation
• Injection of sclerosing agent into TMJ capsule,ligament with or
without arthroscopy.

12. Acute dislocation
• Extrinsic trauma-
• Blow on the chin while the mouth is open
• Injudicious use of mouth gags during GA
• Acute pain, anxiety and inability to close the mouth
• Immediate manual reduction followed by 4 weeks
of immobilization
• Reassuarance of the patient
• Sedatives ,muscle relaxants can be used

13. Digital manipulation
• LA injection into glenoid fossa and manipulation
• Manipulation under GA with the muscle relaxants
• Manipulation under oral or IV sedation

14. Chronic dislocations
• Conservative treatment as first line choice but
surgical management in recurrent cases.
• Physical therapy-Exercises to gain better
masticatory muscles control.

15. Chemical capsulorraphy
• Principle-To induce fibrosis and restrict joint
movement
• 3% sodium tetradecyl sulphate
• Sodium psylliate emulsion in oil
• Sodium morrhuate
• Disadvantage-Inability to predict the amount of
limitation
• Immobilization of the mandible to avoid early
stretching of newly formed fibrous tissue

16. Surgical management
Indications
• Disabling recurrent dislocation
• Long standing dislocation
Contraindication
• Psychological disturbances associated
dislocation
• Epileptic patients

17. Classification of surgical treatment
• In 1976 Miller and Murphy divided it into;
• Capsule tightening procedure
Capsulorraphy, placement of vertical incision,
reinforcement of joint capsule
• Creation of a mechanical obstacle
• Direct restraint of condyle
Temporalis fascia sutured to capsule walford procedure
• Creation of a new muscle balance
• Removal of mechanical obstacle.

18. Capsule tightening procedure/Capsular
plication
Shortening the capsule by removing a section and suturing to
make it tight
• Exposure of capsule followed by incision vertically through
body of ligaments
• Incision margins are overlapped and sutured
• Disadvantage is violation of intracapsular space,can lead to complications
like haemarthrosis.

19. Creation of a mechanical obstacle

23.  Direct restrain of the mandible
• These are to restrain mandible from abnormal forward movements.
• Temporalis fascia turned down and sutured to lateral surface of
articular capsule
• Questionable long term results
 Creation of new muscle balance
• Involves the excision of insertion of lateral pterygoid muscle at
condylar neck and joint capsule, disable the lateral pterygoid
allowing only rotational movements of condyle
• MMF for 7-10 days
• Disadvantage-Difficulty visualizing ,risk of bleeding at highly
vascular site, muscle may reattach making long term efficacy of
procedure in doubt.

26. TMJ Arthritis

27. Rheumatoid arthritis
• Percentage of patients with RA ranges 40-80%
• Disease process starts as vasculitis of synovial
membrane. It progresses to chronic inflammation
marked by intense round cell infiltrate and
subsequent formation of granulation tissue. The
cellular infiltrate spreads from the articular surface
eventually to cause erosion of underlying bone.

29. Clinical manifestations
• TMJs are bilaterally involved in RA
• Limitation of mandibular opening and joint pain
• Pain is usually associated with early acute phases of disease
but not common complaint in later stage
• Morning stiffness
• Joint sounds,tendernes,swelling over joint area
• Symptoms are transient, only small percentage will
experience clinically significant disability
• Most important is pain on palpation of joints and limitation of
opening
• Crepitus may be evident

30. • Micrognathia and anterior open bite are commonly seen in
juvenile RA
• Micrognathia due to direct injury of condylar head and
altered orofacial muscular activity
• Ankylosis of TMJ is rare

32. Radiographic changes
• Narrow joint space
• Destructive lesions of the condyle
• Limited condylar movement
• Little evidence of marginal reparative activity unlike
in DJD
• High resolutions of CT scans will show erosion of
condyle and glenoid fossa that cannot be seen by
conventional radiology.

35. Treatment
• Anti-inflammatory drugs in conjunction with therapy for other
affected joints
• Soft diet during acute exacerbations, but intermaxillary
fixation is to be avoided because of risk of fibrous ankylosis
• Use of flat plane occlusal appliance may be helpful especially
if parafunctional habits are exacerbating the symptoms
• Exercise program to increase mandibular movement
• When patients have severe symptoms, use of intraarticular
steroids
• Prosthesis decrease symptoms in edentulous patients.
• Surgical treatment of joints including placement of prosthetic
joints

36. Juvenile rheumatoid arthritis(Still’s
disease)
• Chronic inflammatory disease that appears before age 16
• Characterised by chronic, intermittent synovial
inflammation that results in synovial hypertrophy, joint
effusion, swollen painful joints
• Gradually bone and cartilage are destroyed
Clinical features
• Pain and tenderness in affected joints
• Unilateral onset
• Severe TMJ involvement may cause restricted
mandibular growth
• Bird face appearance

37. Radiographic features
• Osteopenia(decreased density)initial finding
• Similar findings like RA with addition of impaired mandibular
growth
• Erosions may extend to mandibular fossa and articular eminence
may be destroyed
• Condyle positioned anteroposteriorly in the mandibular fossa
• Hypo mobility at maximal opening.
• Deepening of antegonial notch
• Diminished height of ramus
• Dorsal bending of the ramus and condylar neck.
• Obtuse angle between the mandibular body and ascending ramus
Patients undergoing corticosteroid injections have seen significant
clinical improvement.

38. Psoriatic arthritis
• An erosive polyarthritis occurring in patients with negative
rheumatoid factor who have psoriatic skin lesions
• PA commonly involves fingers and spine. Pitting of nails is observed
in 85% of patients
• TMJ involvement is more common than previously believed.
Clinical manifestations
• Symptoms similar to those in RA except that signs and symptoms
are mostly unilateral
• Limitation of mandibular movement ,deviation to side of the pain,
tenderness over the joint
Radiographic features
• Erosion of condyle and glenoid fossa rather than proliferation.
• Coronal CT shows TMJ changes of psoriatic arthritis.

39. Treatment
• Management similar to RA with emphasis on physical therapy
and NSAIDS that control pain and inflammation
• Antimalarial drugs should not be used because they cause
severe skin erosions in patients with psoriasis.
• Immunosuppressive drugs used for patients with severe
disease that does not respond to conservative treatment.
• Only in TMJ pain or limited mandibular movement is surgery
indicated.
• Arthroplasty or condylectomy with placement of
costochondral grafts
• Surgery may be complicated by psoriasis forming in the
surgical scar(Koebner effect)

40. Septic arthritis
• Occurs in patients with previously existing joint disease such as RA
or diabetes
• Patients taking immunosuppressant have an increased risk of septic
arthritis. Infection may result from blood borne bacterial infection
or extension of infection from adjacent sites such as middle ear
,maxillary molars and parotid gland
Organisms
• Gonococci –most common in previously normal TMJ
• Staphylococcal aureus –previously arthritic joints
Symptoms
• Trismus
• Deviation of the mandible to the affected side
• Severe pain on movement
• Inability to occlude teeth due to inflammation in the joint space .

41. Examination
• Redness and swelling in the affected joint
• Large tender cervical lymph nodes on the side of the infection
• Diagnosis by detection of bacteria on gram stain and culture of
aspirated joint fluid.
Sequale
Osteomyelitis of temporal bone
Brain abscess
Ankylosis
Facial asymmetry may accompany septic arthritis of TMJ especially
children
Evaluation of patients must include review of signs and symptoms of
gonorrhoea such as purulent urethral discharge and dysuria
Affected TMJ should be aspirated and fluid tested by gram stain and
cultured for Neisseria gonorrhoeae

42. Treatment
• Surgical drainage, joint irrigation and 4-6 weeks antibiotics.
Gout and pseudo gout arthritis
Gouty arthritis of TMJ is rare although crystal deposition may be
apparent in tissues adjacent to the joint
Acute attack may be successfully treated with colchicine,NSAIDS
or intraarticular steroids.