Temporomandibular joint disorders II

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Oral & Maxillofacial Surgery
Fifth Year

Published in: Health & Medicine

Temporomandibular joint disorders II

  1. 1. Internal Derangements Dr. Wael M. Talaat Assistant Professor of Oral & Maxillofacial Surgery University of Dammam
  2. 2. Overview         Definition Prevalence Disc Displacements Pathogenesis Etiology Symptoms Diagnosis Treatment
  3. 3. What to gain ??? 1. 2. 3. 4. 5. Understand Internal Derangements and its underlying causes Be able to diagnose Disc Displacements Choose the correct line of treatment Arthrocentesis, when, how, why ??? Future Directions
  4. 4. Definition  The Temporomandibular Joint (TMJ) is a common site of complaint. Clicking sounds and pain are indicators of a frequent condition called internal derangement, most often affecting females. As a general term, internal derangement describes a structural abnormality within an articulation.
  5. 5.  The internal derangement of the temporomandibular joint (TMJ) is a specific term defined as an abnormal positional and functional relationship between the disk and articulating surfaces.
  6. 6.  Emshoff R. and Rudisch A. (2003) defined internal derangements of the temporomandibular joint as an abnormal relation of the articular disc to the mandibular condyle and the articular eminence. Jaw pain, clicking of the joint, irregular and limited movement of the jaw are the characteristic symptoms of this disorder.
  7. 7. Prevalence Is TMJ Disorder a common disorder?  Internal derangement and associated complications are the most common pathologic entities affecting the jaw. Solberg W.K. (1979)
  8. 8.  Nebbe et al (2000) in his study on prevalence of TMJ disc displacement found normal joints in only 50% of boys and in 23%–29% of girls. The rest of the study population presented with different degrees of slight to full disk displacement with or without a change in morphology. In other studies, asymptomatic disk displacement was documented in approximately 30% of adolescents.
  9. 9.  82% of patients presenting with pain and functional disturbance of their TMJ will have displaced disks when examined with magnetic resonance imaging. The overall prevalence of symptomatic disk displacement or internal derangement may range between 20% and 30%, making them frequently encountered conditions.
  10. 10.  The National Institute of Dental and Craniofacial Research indicates that 10.8 million people in the United States suffer from TMJ problems at any given time. Both men and women experience TMJ problems; however, 90 percent of those seeking treatment are women in their childbearing years.
  11. 11. Disc Displacements   Anterior disk displacement of the TMJ is a malrelationship of the disk to the condylar head and articular eminence. Although the disk may displace medially, laterally, or (rarely) posteriorly to the condyle, it generally displaces anteriorly. First stage in the sequence of events leading to osteoarthritis.
  12. 12.  TMJ morphology, have shown a path of progression that includes changes not only in the disc position, but also in its configuration. The interpretation of the process leading up to a dislocated disc as portrayed in the literature does not always stand on firm evidence and at times is contradictory.
  13. 13.  Disc displacement is considered to be associated with clinically noticeable clicking noises on opening and closing of the mouth as long as the disc reduces to its normal position on opening. When it becomes nonreducible, the clicking noise disappears and instead there is a certain degree of limitation in mouth opening.
  14. 14. Classification of Disc Displacements  Internal derangements can be divided into 2 categories: anterior disk displacement with reduction and anterior disk displacement without reduction. The condition in which the disk is located anteriorly and slips back into its normal position during opening of the mouth is called anterior disk displacement with reduction; the opposite condition is dubbed anterior disk displacement without reduction.
  15. 15. Anterior disk displacement with reduction
  16. 16. Anterior disk displacement without reduction
  17. 17. Pathogenesis    TMJ disc displacement results from its inability to slide smoothly due to increased friction or degenerative changes in the joint surfaces. The sequence of events, starting with increased friction in the upper joint compartment and culminating in disc displacement Activation of various parafunctions, such as clenching, compromises the lubrication system in the upper TMJ compartment.
  18. 18.   The resulting increased friction prevents the disc from sliding together with the condyle. On jaw opening, the condyle is pulled away from the disc by the inferior head of the lateral pterygoid muscle. As a result, the ligaments joining the disc to the condyle are gradually stretched, and the ‘mobilized’ disc gravitates slightly downward and forward.
  19. 19.  Subsequently, on clenching, the unstable disc is propelled forward by pressure from the condyle. At this point, the force on the slightly displaced disc is shared between two vectors, one of which is directed forward. Apparently, on mouth closure, the superior belly of the lateral pterygoid muscle pulls the disc anteriorly
  20. 20.  Subsequently, during mouth opening, the condyle, which is now posterior to the loose disc, gradually pushes it down the slope of the eminence, displacing it further forward
  21. 21.  Since the lateral articular disc bears the bulk of the shearing and compressive loads, persistent loading tends to drive it in a medial direction, which is the ‘path of least resistance’.
  22. 22. Etiology 1. 2. 3. 4. 5. TRAUMA FUNCTIONAL OVERLOADING JOINT LAXITY MASTICATORY MUSCLE SPASM INCREASED FRICTION
  23. 23. Symptoms  1. 2. 3. 4. Disc Displacement With Reduction: Pain Joint sounds (single, short duration) Catching sensation during mouth opening Deviation in opening pathway
  24. 24.  1. 2. 3. 4. 5. Disc Displacement Without Reduction: Limited mandibular opening Normal eccentric movement to the ipsilateral side Restricted eccentric movement to the contralateral side. Pain Joint sounds ( long duration sounds )
  25. 25. Diagnosis 1. 2. Clinical evaluation a. History b. Physical examination TMJ clicking Pain Limitation of mandibular opening Radiographic evaluation: Magnetic Resonance Imaging
  26. 26. MRI imaging using Sigma (General Electric Co. Wisconsin) machine
  27. 27. Disc displacement with reduction (arrows pointing to the disc)
  28. 28. Disc displacement without reduction (arrows pointing to the disc)
  29. 29. Treatment  1. 2. 3. 4. Extrajoint therapy: Splint therapy Therapeutic manipulation Physical therapy Drug therapy
  30. 30.  1. 2. 3. Intrajoint therapy: Surgical treatment Arthroscopy Arthrocentesis
  31. 31. Arthrocentesis  Nitzan et al (1991) described a technique of irrigation of the upper compartment of the TMJ with Ringer's lactate solution to treat limited mouth opening due to internal derangement. The authors called this technique `arthrocentesis'.
  32. 32.  They reported an increase in mouth opening from a range of 12±30 mm prior to the procedure, to 35±50 mm following it. On a visual analogue scale of 0±15, the pain decreased from a mean rating of 8.75 to 2.3. This technique marked an evolution towards less surgical treatment.
  33. 33.  Arthrocentesis is the most recent surgical approach for internal derangement of the TMJ. In the past many cases of anterior displacement of the disc or closed lock that did not improve with medical treatment (bite plates, muscle relaxants, diet and physical therapy) were initially treated with surgical repositioning of the disc and arthroplasty of the mandibular fossa.
  34. 34.  Arthrocentesis has an intermediate place between the medical and the surgical forms of treatment. Ease, lower cost of materials and excellent published results so far include this technique in the international protocol for the treatment of TMJ dysfunction.
  35. 35.  Arthrocentesis is a simple yet effective treatment of temporomandibular joint disorders, and it requires minimal invasion. Significant improvements in width of mouth opening have been reported with proven long-term results. It is speculated that the increase in mouth opening results from the elimination of the vacuum effect within the joint compartment.
  36. 36.  In 2003, Reston and Turkelson performed a meta-analysis of surgical treatments for temporomandibular articular disorders. They concluded that among patients refractory to nonsurgical therapies, surgical arthrocentesis and arthroscopy were most effective for patients with disc displacement without reduction.
  37. 37.  It is suspected that lavage under sufficient hydraulic pressure could widen the narrowed joint space and release adhesion in the joint space. Arthrocentesis with sufficient pressure could be effective for closed lock cases with adhesions in the upper joint compartment.
  38. 38. Mechanism of Action 1. Reduction in pain level: Arthrocentesis reduces pain by removing inflammatory mediators from the joint. The combined treatment of arthrocentesis and Sodium Hyaluronate injection may improve the results due to the long-term lubricating effect of Sodium Hyaluronate, which prevents the onset of inflammatory mediators that are responsible for pain.
  39. 39. 2. Maximal Mouth Opening: Arthrocentesis under high pressure is an effective method to regain normal mouth opening in closed lock cases. This effect is usually due to elimination of the adhesions around the disc. Also the lubricating effect of Sodium Hyaluronate which either maintains lubrication and minimizes wear and tear mechanically, or plays a role in nutrition of the avascular parts of the disc and condylar cartilage.
  40. 40. 3. Clicking : Usually disappears due to decreased friction and lubricating effect.
  41. 41. Technique
  42. 42. “Relationship between the Canthal-Tragus Distance and the Puncture Point in Temporomandibular Joint Arthroscopy” Wael Talaat Taha1, PhD, Thomas A. McGraw 1, DMD, and Bruce Klitzman1, PhD Int J Oral Maxillofac Surg. 2010; 39: 57 - 60
  43. 43. Nearby Vital Structures  The frontal branch of the facial nerve is located a mean distance of 20 mm from the anterior margin of the bony external auditory canal as it crosses over the posterior aspect of the zygomatic arch (a range of 8 to 35mm). The main trunk of the bifurcation of the facial nerve is located a mean distance of 23 mm (a range of 15 to 28 mm) inferior to the lowest concavity of the bony external auditory canal.
  44. 44.  Greene MW et al found the tympanic plate to be located at a range of 6 to 9 mm anterior to the posterior tragus and perpendicular to the skin at a mean depth of 25.4 mm (range = 19 to 32 mm).
  45. 45. Future Directions  . In 2006, Betre et al designed a biologically based drug delivery vehicle for intra-articular drug delivery using elastin-like polypeptides (ELPs), a biopolymer composed of repeating pentapeptides that undergo a phase transition to form aggregates above their transition temperature. The ELP drug delivery vehicle was designed to aggregate upon intra-articular injection at 37 °C, and form a drug ‘depot’ that could slowly disaggregate and be cleared from the joint space over time.
  46. 46. Thank You

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