TMJ

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TMJ

  1. 1. * Introduction * Anatomy * Radiographic examination * Myo functional pain dysfunction syndrome * TMJ disorder * Dx of TMJ disorder * Rx of TMJ disorders
  2. 2. Definition : It is the joint formed by temporal bone with the mandible It`s actually a sliding joint not only ball & socket Site : In front of each ear
  3. 3. Structure of TMJ 1- articulating surfaces A (bony elements) condyle Glinoid fossa
  4. 4. Interatricular disc Cartilaginous disc placed between the 2 bony elements The disc is attached to a muscle (lateral pterygoid) & moves with certain movement of TMJ
  5. 5. Joint capsule It surrounds TMJ It is attached to glinoid fossa margin & the neck of condyle *It maintain proximity of joint parts during function *It limits forward translation of the condyle
  6. 6. Synovial membrane It is the internal lining of external capsule It contains synovial fluid for lubricating the joint
  7. 7. Diagnosis of TMJ disorder Comprehensive history (onset,duration,course,pasthistory,surgical procedures,family history) Physical examination (palpation ,stethoscope,dentition) Radiographic diagnosis Lab investigations
  8. 8. Radiographic examination To evaluate condition of teeth , bone , surrounding hard & soft tissue Plain x-ray (a To see changes in bony structure only Ex : panoramic , oblique lateral
  9. 9. Tomography It is of a great value in dx of TMJD… It has the property of elimination of superimposition in plain x rays
  10. 10. Arthrography They r taken after injecting die material into synovial spaces to enhance intra capsular soft tissue
  11. 11. C.T scan It`s x-ray images in serial manner with different levels showing hard & soft structures v. Helpful in Dx of TMJD inspite of high dose of exposure
  12. 12. MRI It`s efficient in detecting changes in soft tissues Limited accuracy in detecting bony elements Helpful in DX of (internal derangement)
  13. 13. Arthroscopy It allows detection of internal abnormality by direct vision through arthroscope
  14. 14. Lab investigations CBC Serum calcium Serum phosphorus & alkaline phosphatase Serum uric acid ESR Serum RF
  15. 15. functional Myofunctional pain dysfunction syndrome Organic Acquired (arthritis-dislocation-ankylosisinternal derangement) Congenital (condylar hypo/hyperplasia)
  16. 16. It`s a painful condition of skeletal muscles specially the muscles of mastication Characterized by development of trigger points or sensitive painful area in muscle or junction bet muscle & facia
  17. 17. Signs & symptoms 1- Pain -it`s the most complain -mostly unilateral -dull - sharp & acute Location Back of head & neck Temporal area Angle of jaw The area in front of ear
  18. 18. 2-tenderness of muscles of mastication Temporal muscle is the common muscle to produce temporal pain Masseter : trigger points Refer pain to : (sinus area, Ear , above eye & even into molar region )
  19. 19. Trapezius muscle : Pain almost referred to head & face Medial pterygoid muscle : Trigger points refer to ( TMJ , nose ,ear , lower jaw & lateral side of neck )
  20. 20. Sternomastoid muscle: Develops trigger points with or w/out TMJ problems Cause forehead headache (misdiagnosed with frontal sinusitis ) Also may cause pain in (ear, over &around aye ,chin & below the eye (mis diagnosed with max sinusitis ) )
  21. 21. 3-clicking in TMJ during movement - It is the most common symptom (it may be so loud ) - There may be pain in joint during chewing
  22. 22. 4- limitation of mandibular movement 5-absence of clinical or radiographic evidence of Organic changes in TMJ 6- No tenderness of TMJ during examination
  23. 23. Etiology of MPD occlusal disharmony psychological stress
  24. 24. Diagnosis of MPD 1- History. 2-Determine the range of mouth opening. 3- Radiographic examination showing no organic changes. 4-Determine the direction & amount of mandibular deviation during opening. 5-Examination of TMJ by palpation & auscultation & palpation of muscles of mastication
  25. 25. Treatment of MPD Control pain & discomfort Correction of occlusal disharmony Removal of psychological stress & tension
  26. 26. Immobilization of jaw It produce complete rest for 2-3 weeks Use of Boxer`s mouth guard (to separate occlusal surfaces )
  27. 27. Correction of occlusal disharmony 1- occlusal adjustment : by selective grinding to remove cusp interference between teeth To maintain occlusal stability & equilibrium of muscle during rest position
  28. 28. 2- Anterior deprogrammer : * Suppresses clenching intensity ** Prevent occlusal wear & trauma 3-splints & occlusal bite planes : Acrylic splints made with simultaneous contact of mandibular teeth in centric occlusion to eliminate muscular spasm
  29. 29. Thermo therapy By heat application to activate blood circulation of spastic muscles
  30. 30. Muscle exercise It stimulate weak muscles & wash metabolites so decrease spasm Intra muscular injection of L.A : Help in diagnosis of the syndrome & in cuts cycle of pain
  31. 31. Psychological therapy Emotional stress stimulate vascular dynamics (contraction & dilatation ) so increasing muscular tone leading to spasm Administration of muscle relaxant
  32. 32. Acquired organic disorders of TMJ 1- Inflammatory. 2- Degenerative. 3- Infectious. 4- Traumatic.
  33. 33. Rheumatoid arthritis It`s a systemic inflammatory disease that produce destructive changes to the joints (may affect more than one joint ) c/p: Pain , joint noise ,limitation of movement , malocclusion ) Juvenile RA : impairment of jaw growth & may lead to ankylosis
  34. 34. Diagnosis of R.A Clinically : multiple joint involvement Lab investigations : RH factor Radiographic examination : (lack of joint space d.t condylar destruction ) - Condyle is eroded ,flattened & rarefied - Glinoid fossa is shallow
  35. 35. Treatment *application of moist heat *anti inflammatory drugs *immunosuppressive drugs *Gold salts *steroids (oral – joint injection)
  36. 36. Degenerative arthritis (osteoarthritis) Non inflammatory focal degenerative disorder that affect primarily articular cartilage and sub condylar bone (initiated by deterioration of articular soft tissue cover & exposure of bone ) Cause : long term functional abuse
  37. 37. C/P : *Crepitation sound from joints *Restricted or normal mouth opening *With or w/out pain *Occasionally may joints show inflammatory signs *Women > Men *Tenderness of muscles of mastication *Limitation of mandibular movement & deviation to the affected side *Tenderness over condyle
  38. 38. Diagnosis Based on clinical & radiographic examination (irregularity of condylar surface & radiolucency in substance of condyle )
  39. 39. Treatment Analgesics Anti inflammatory drugs Muscle relaxant Surgery (condylar shaving or high condylectomy )
  40. 40. Infectious arthritis It is the consequence of direct extension from middle ear , parotid gland & posterior areas of mandible it is also happened after trauma followed by infection from septseamia Leads to inflammation of synovial tissues Leads to destruction of fibro cartilage & bone leading to ankylosis
  41. 41. Treatment Administration of antibiotics Drainage of source of infection Rest analgesics
  42. 42. Occurs d.t trauma to the joint There is muscular tear , ligamentous injury Hemarthrosis may be present Mechanical damage to surrounding structure may be present
  43. 43. Diagnosis History of severe trauma with pain , swelling , & dysfunction Only the affected joint showing inflammation Presence of normal joint function before trauma Treatment : Rest , Administration of analgesics , anti inflammatory drugs
  44. 44. Congenital condylar disorders Condylar hypoplasia Condylar hyperplasia Others
  45. 45. Benign tumors 1- synovial chondromatosis : Benign tumor characterized by cartilaginous metaplasia of synovial membrane producing small nodules which separate form membrane to become loose bodies that may ossify
  46. 46. 2- osteochondroma Benign tumor characterized by normal bone & cartilage near growth zones
  47. 47. Osteoma Osteoma is a benign tumour consisting of mature bone tissue. It is a slow growing, asymptomatic
  48. 48. Anterior (to eminence) Lateral (in temporal fossa) Dislocation of TMJ Posterior (in fracture of base of skull ) Superior (into medial cranial fossa)
  49. 49. Signs & symptoms of dislocation - Mandible fixed in open position - Protrusion of chin - Deviation to the normal side By palpation depression is noticed in front of the ear - Limitation of movement - Pain -
  50. 50. Treatment of dislocation Acute dislocation : Manual reduction under sedation or even under G.A with muscle relaxant Then immobilization for several days ..
  51. 51. Chronic dislocation - Manual reduction with L.A or G.A & muscle relaxant - Surgical exposure of joint & direct reduction - Condylectomy - Condylotomy
  52. 52. 3- Recurrent dislocation Conservative RX : immobilization for several days Injection of sclerozing material around capsule to produce fibrosis Surgical RX : re-situation of capsule & ligament Ligation of condyle Removal of eminence Removal of activating muscle
  53. 53. TMJ ankylosis It is fibrous or bony union between joint components It is unilateral or bilateral Partial or complete True or false (When the structures outside the joint are affected)
  54. 54. False ankylosis Muscular trismus Muscular atrophy or fibrosis Myositis ossificans Tetanus Neurogenic closure of mouth
  55. 55. Etiology Birth trauma Heamarthrosis Suppurative arthritis Rheumatoid arthritis Osteomyelitis Fracture condyle
  56. 56. Clinical findings - Inability to open mouth - Gradual development of jaw immobilization - Slight opening mouth in unilateral affection
  57. 57. - Bird face ,micrognathia, mal occlusion & impacted teeth - Deviation of mandible to the affected side
  58. 58. Treatment * If fibrous ankylosis : Open the mandible manually under G.A
  59. 59. * Condylectomy * Osteoarthrotomy * Repalcement of condyle
  60. 60. Abnormal relationship between articular disc to condyle & eminence
  61. 61. Symptoms Pain during function Joint clicking or noise Earache or headache Facial pain
  62. 62. Ant. Displacement of the disc (with reduction)(clicking) Ant. dislocation of the disc (w/out reduction) (locked joint).
  63. 63. Treatment Conservative treatment Surgical treatment Occlusal therapy :Selective grinding. Construction of splints. Relocation of disc: meniscoplasty Condylotomy. Capsular rearrangement of the meniscus. High condylectomy Physiotherapy :Soft diet , muscular exercises. Muscle relaxants.

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