Tmj disorders /certified fixed orthodontic courses by Indian dental academy


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Tmj disorders /certified fixed orthodontic courses by Indian dental academy

  1. 1. TEMPOROMANDIBULAR JOINT INDIAN DENTAL ACADEMY Leader in continuing dental education 1
  2. 2. “Those who fall in love with practice without science are like a sailor who enters a ship without a helm or compass, and who never can be certain whither he is going.” - Leonardo da Vinci 2
  3. 3. HISTORICAL PERSPECTIVE • Dr James Costen -1934 • Late 50”s – investigations on TM disorders • Shore -1959 • Late 70”s – occlusion and emotional stress • 1980-dental profession recognized fully and appreciate the complexity 3
  4. 4. HISTORICAL PERSPECTIVE • Costen –TMJ disturbances • Shore – TMJ dysfunction syndrome • Ramjford and Ash – functional TMJ disturbances • Bell –TM disorders Temporomandibular disorders 4
  5. 5. History and examination • Screening history-difficulty or pain in opening -jaw getting “locked” -pain during chewing -history of sounds -pain in ear, cheek -headaches -recent injuries -previous treatment for joint problems 5
  6. 6. History and examination • Pain-location -behavior -quality -duration -degree • Dysfunction • Onset • Emotional stress 6
  7. 7. History and examination • Clinical examination-Cranial nerve examination-5th and 7th -cervical examination -neuromuscular examination -intracapsular disorders -TMJ examination-pain ,sound, restrictions. 7
  8. 8. History and examination • Cranial nerve • • examination-5th Sensory-lightly stroking face with a cotton tipforehead,cheek,lower jaw Motor-asking the patient to clench 8
  9. 9. History and examination • 7th nerve• Sensory component-taste sensation • Motor component- raise both eyebrows ,smile and showing lower teeth . 9
  10. 10. History and examination • Cervical examination• Evaluating the neck for pain and or movement difficulties 10
  11. 11. History and examination • Neuromuscular examination- • Temporalis muscle -anterior -middle -posterior 11
  12. 12. History and examination • Masseter muscle -deep part -superficial part 12
  13. 13. History and examination • Sternocleidomastoid- 13
  14. 14. History and examination • Posterior cervical muscles- 14
  15. 15. History and examination • Functional manipulation-Inferior lateral pterygoid -Superior lateral pterygoid -Medial pterygoid 15
  16. 16. History and examination • Evaluating Interincisal distance “End Feel” 16
  17. 17. History and examination • Differentiating Deviation Deflection 17
  18. 18. History and examination • TMJ examination - joint pain 18
  19. 19. History and examination • Examination of dentition-mobility -pulpitis -tooth wear -CR and CP -occlusal contacts in various movements 19
  20. 20. Diagnostic Tests • Imaging of TMJ1. Radiographic technique - a pure lateral view of condyle is impossible with conventional x-ray • Panoramic • Transcranial • Transpharyngeal • Transmaxillary 20
  21. 21. Problems With TMJ Viewing 21
  22. 22. Diagnostic Tests 1. Panoramic view – - commonest . -provides the screening of the condyle. -both condyles are visible in a single film. -for best view – mouth open position. 22
  23. 23. Diagnostic Tests • Lateral transcranial view-good visualization of condlye and fossa -quite popular -patient-head positioner. - rays are directed inferiorly . 23
  24. 24. Diagnostic Tests • Transpharyngeal view -similar to panoramic -rays are directed from either below the angle of mandible or through the sigmoid notch -demonstrates the condyle satisfactorily ,fossa is not well visualized . 24
  25. 25. Diagnostic Tests • Transmaxillary projection(AP) view -mouth is wide open. -condyles translated out of the fossa. - Excellent view for evaluating fracture of the condylar neck. 25
  26. 26. Diagnostic Tests • Tomography – -introduced by Petrilli in 1936 -to overcome the problem of superimposition -ability to image an object in multiple layers at desired tissue depth. 26
  27. 27. Diagnostic Tests • Technology and equipment• Uses coordinated motion of x-ray • source and film to produce varying degree of image blurring ,minimized in the plane of interest. Anatomic layer of interest is placed at the imaginary Crot. 27
  28. 28. Diagnostic Tests 28
  29. 29. Diagnostic Tests • Disadvantage – - Dense structure - parallel to the beam may reduce image clarity Spurious contours 29
  30. 30. Diagnostic Tests • Useful for• • • • Diagnosis of osseous defects. Condylar fractures ,lesions, tumors. Signs of degenerative diseases. Pain without clinical signs. 30
  31. 31. Diagnostic Tests • Arthrography - Introduced by Norgaard-1947 - First imaging technique capable of providing - information on soft tissue status. Involves injecting radiopaque contrast material into one or both of the joint spaces ,outlining the disk between the opaqued joint space. 31
  32. 32. Diagnostic Tests • Single contrast arthrography – -medium is injected into the lower joint space -with fluoroscopy or tomography . • Double contrast arthrography-sequential injections of contrast material with small amount of air. 32
  33. 33. Diagnostic Tests • Computerized tomography• it is one of the first techniques which applies • • computer and data storage technology to enhance the capabilities of the conventional techniques. Provides both hard and soft tissue information on both joints from a single examination. No invasive injections . 33
  34. 34. Diagnostic Tests 34
  35. 35. Diagnostic Tests 35
  36. 36. Diagnostic Tests • Magnetic Resonance Imaging (MRI) • Introduced by Helms, Ketzberg • It exploits the varying proton (water) content of • • different tissues . Protons in tissue fluids are polar . When they are exposed to strong magnetic field of the MRI scanner ,some protons align parallel with direction of the external field. 36
  37. 37. Diagnostic Tests 37
  38. 38. Diagnostic Tests • Is useful in-obtaining cross sectional images at varying tissue depth -better visualization of the soft tissues. -disc displacement. -Amount of synovial fluid . 38
  39. 39. Diagnostic Tests • Sonography• It is a technique of recording and graphically demonstrating joint sounds. • Some utilizes audio amplifying devices while others rely on ultrasound echo readings • Reliability is questionable. 39
  40. 40. Diagnostic Tests • Thermography – • It is a technique that records and graphically illustrates surface skin temperature . • Various temperatures are recorded by different colours producing a map that depicts the surface being studied. 40
  41. 41. Diagnostic Tests • In summary• Radiographs alone have limited role in diagnosis TMD. • Transcranial and panoramic views are used as screening devices . • Tomography is reserved for patients if screening radiographs reveal a possible abnormality . 41
  42. 42. Diagnostic Tests • Arthrography is a specialized diagnostic tool to be used only when doubt exists regarding the position of the articular disc. • CT and MRI-to be used only when additional information will significantly improve the establishment of a proper diagnosis . 42
  43. 43. TMD • TMD-in a broad sense are to be considered a cluster of joint and muscle disorders in the orofacial area characterized primarily by pain, joint sound and irregular or deviating jaw functions 43
  44. 44. TMD N A P 44
  45. 45. Classification system of TMD’s • Masticatory muscles disorder- Protective co contraction - Local muscle soreness - Myofacial pain - Myospasm - Myositis 45
  46. 46. Classification system of TMD’s • TMJ disorders I-Derangement of the condyle disc complex 1. disc displacement 2. disc dislocation with reduction. 3. disc dislocation without reduction. II-Structural incompatibility of articular surface 1.Deviation in form 2.Adhesions 3.Subluxation 4.Spontaneous dislocation. 46
  47. 47. Classification system of TMD’s • Inflammatory disorders of the TMJ -synovitis. -capsulitis. -retrodiscitis. -arthritides. -inflammatory disorders of associated structures. 47
  48. 48. Classification system of TMD’s • Chronic mandibular hypomobility -ankylosis. -muscle contracture. -coronoid impedance. • Growth disorders-agenesis -hypoplasia -hyperplasia -neoplasia 48
  49. 49. Classification system of TMD’s • Congenital and developmental disorders-hypertrophy -hypotrophy -neoplasia. 49
  50. 50. Masticatory Muscle Model 50
  51. 51. Anatomy of the joint space 51
  52. 52. TMD’s Derangement of condlye disc complex 1.Disc displacement• Etiology- breakdown of the normal rotational function of the disc - elongation of the discal ligament and inferior retrodiscal lamina. 52
  53. 53. TMD’s • History –of trauma associated with the onset of joint sound • C/F – joint sound during opening and closing. -when reciprocal clicking is present ,two clicks normally occur at different degree of opening and closing 53
  54. 54. TMD’s 2.Disc dislocation with reduction• Further thinning of the posterior border leads to the slipping of the disc completely • History –long history of clicking and more recent catching sensation. 54
  55. 55. TMD’s • C/F –unless the jaw is shifted to the point of reducing the disc ,pt. presents with limited range of movement. -in some cases sudden loud pop is heard 55
  56. 56. TMD’s 3.Disc dislocation without reduction • Elasticity of superior retrodiscal lamina is lost ,recapturing of the disc becomes more difficult • When this happens condyle merely forces the disc in front of the condyle. 56
  57. 57. • History- • TMD’s -pt. give a precise history of when the dislocation occurred. -pain may be present but not always C/F-range of mand. opening is 25-30mm -maximum point of opening reveals a hard end feel 57
  58. 58. TMD’s • Structural incompatibilities of articular surface 1.Deviation in formEtiology-change in the shape of the articular surfaces History –presence of a long term dysfunction. C/F –dysfunction occurs at a particular point of movement . 58
  59. 59. TMD’s 59
  60. 60. TMD’s 2.Adhesions – Etiology-prolonged static loading -macrotrauma -surgery C/F-superior joint space adhesion -translation is inhibited –only rotational . -mandibular opening of 25 – 30 mm. -fixed disc /posterior disc dislocation. 60
  61. 61. TMD’s • C/F-inferior joint space adhesion - difficult to diagnose -normal translation but rotational –lost. - catching or jumping on maximum opening. 61
  62. 62. TMD’s 3.Subluxation (hypermobility) – -Sudden forward movement of the condyle during later phase of mouth opening . Etiology –normal joint movement as a result of certain anatomic features. History- jaw “going out” during wide opening 62
  63. 63. TMD’s • C/F -can be observed clinically by asking the pt. to open wide. -as the condyle jumps out a small void or depression is visible. -midline pathway shows a deviation. -no pain is associated unless repeated often. 63
  64. 64. TMD’s • Spontaneous dislocation• Represents a hyperextension of the TMJ • leading to anterior dislocation of the disc. Etiology –same as in joints with subluxation 64
  65. 65. TMD’s • History –dislocations are usually associated with wide mouth opening procedures . • C/F-pain - “open lock”. 65
  66. 66. TMD’s • Arthritides –refers to the inflammation of the • • • • articular surface. Osteoarthriitis and osteoarthrosisEtiology-when articular surface of the joint can no longer tolerate the effect of loading. History-unilateral joint pain -constant pain C/F-limited mandibular opening -crepitations -structural changes in the radiograph. 66
  67. 67. TMD’s • Ankylosis• By definition –means abnormal immobility of the joint. • Classified as-based on the 1.Site 2.Tissue involved. 3.Jaw joint . 67
  68. 68. TMD’s • Etiology-Macrotrauma -abnormal intrauterine development -birth injuries -condylar fractures -inflammation of the joint -surgery -infection. 68
  69. 69. TMD’s • C/F-diminished growth of the mandible -total immobility -micrognathia -deviation during mouth opening -poor oral hygiene. 69
  70. 70. General considerations in the treatment of TMD’s • Three conditions exist that tend to promote this condition- 1. Lack of adequate scientific evidence . 2. Etiologic factors –difficult to control. 3. Some factors that are yet to identified . 70
  71. 71. General considerations in the treatment of TMD’s Treatment approach Definitive treatment Supportive treatment 71
  72. 72. General considerations in the treatment of TMD’s • Definitive treatment-Occlusal therapy -reversible -irreversible -Emotional stress therapy - patient awareness. -voluntary avoidance. -relaxation therapy. 72
  73. 73. General considerations in the treatment of TMD’s • Occlusal therapy –is considered to be any kind of treatment that is directed towards altering the mandibular position and/or occlusal contact pattern of the teeth. 1. Reversible - that alters patient occlusal condition temporarily 73
  74. 74. General considerations in the treatment of TMD’s 2. Irreversible –which permanently alter the occlusal condition and /or mandibular position Reversible Irreversible 74
  75. 75. General considerations in the treatment of TMD’s • Emotional stress therapy- - Patient awareness . - Voluntary avoidance . - Relaxation therapy. -substitutive -active 75
  76. 76. General considerations in the treatment of TMD’s I. Supportive therapy -Pharmacological therapy -analgesics -antianxiety -antiinflammatory -muscle relaxants -LA 76
  77. 77. General considerations in the treatment of TMD’s II.Physical therapy - modalities - manual techniques. Thermotherapy - utilizes heat as a prime mechanism 77
  78. 78. General considerations in the treatment of TMD’s Coolant therapy - relaxation of muscles Ultrasound therapy - increase in the temperature at the interface of the tissue and therefore affects deeper tissue 78
  79. 79. General considerations in the treatment of TMD’s • Iontophoresis –is a technique by which certain medications can be introduced into the tissues . • TENS –brings about continuous stimulation of cutaneous nerve fibers thereby decreasing pain perception. 79
  80. 80. General considerations in the treatment of TMD’s TENS 80
  81. 81. General considerations in the treatment of TMD’s • Manual technique- Soft tissue mobilization- - gentle massage of the soft tissue overlying the painful area. Restricted use ,relaxation therapy. 81
  82. 82. General considerations in the treatment of TMD’s Joint distraction 82
  83. 83. Thank you For more details please visit 83