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. TMJ Disorders INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Contents         Introduction Epidemiology Etiology Classification Clinical features Radiological features Histological pathologic features Treatment
  3. 3. Introduction  TMD – cluster of joint and muscle disorders in the orofacial area characterized primarily by  Pain  Joint sound and  Irregular or deviating jaw functions
  4. 4. Epidemiology  Epidemiologic studies has shown that 60-70% of the general population have functional disturbances of the masticatory apparatus.  Most prevalent between the ages of 20-40 years and predominantly affects women.
  5. 5. Etiology  Multifactorial  Parafunctional habits .  Emotional stress.  Acute trauma from blows / impacts.  Trauma from hyperextension.  Instability of maxillo-mandibular relationships.  Laxity of the joints.  Rheumatic / musculo-skeletal disorders.  Poor general health and unhealthy lifestyle.
  6. 6. Classification MUSCULAR DISORDERS  Hyperactivity, spasm, and trismus  Inflammation (myositis)  Trauma  Myofascial pain and fibromyalgia  Atrophy or hypertrophy ARTHROGENIC DISORDERS  Disc displacement (internal derangement)  Hypomobility of the disc (adhesions or scars)  Dislocation and subluxation  Arthritis  Infections  Metabolic disease {gout, chondrocalcinosis)  Capsulitis, synovitis  Ankylosis (fibrous, bony)  Fracture  Condylar hyperplasia, hypoplasia, aplasia  Neoplasia Neville
  7. 7. Classification  Developmental anomalies        Osteoarthrosis Rheumatoid arthritis Inflammatory arthritis Infective arthritis       Ex. Condylar hyperplasia. Condylar hypoplasia. Condylar Aplasia Local middle ear infection Systemic infection (e.g. gonococcal). Neoplasia Metabolic disease (ex. Gout, chondrocalcinosis). Synovial disease (Ex. PVNS) Miscellaneous conditions (Ex: Paget’s disease of bone, acromegaly). CD Franklin
  8. 8. Classification  Intracapsular disorders of the TMJ Source Disorder Degenerative (non-inflammatory) Degenerative joint disease Inflammatory Rheumatoid arthritis Psoriatic arthritis Infections Spread from contiguous site Developmental Condylar hyperplasia, hypoplasia and agenesis Traumatic Condylar fracture, ankylosis, dislocation and disc displacement. Burket’s
  9. 9. Classification I. Developmental disturbances of the TMJ    Aplasia of the mandibular condyle Hypoplasia of the mandibular condyle Hyperplasia of the mandibular condyle II. Traumatic disturbances of the TMJ    Luxation and subluxation (complete and incomplete dislocation) Ankylosis (hypomobility) Injuries of the articular disk (meniscus) III. Fractures of the condyle IV. Inflammatory disturbances of the TMJ    Arthritis Rheumotoid arthritis Osteoarthritis (degenerative joint disease, hypertrophic arthritis)
  10. 10. Classification V. Neoplastic disturbances of the TMJ VI. Extra-articular disturbances of the TMJ VII. Temporomandibular joint syndrome (TMD) TMD secondary to myofacial pain and dysfunction (MPD)  TMD secondary to true articular disease. 
  11. 11. I. Developmental disturbances of the TMJ 1. Aplasia of the mandibular condyle    Cl/ft:      Condylar aplasia or failure of development of the mandibular condyle  which may occur unilaterally or bilaterally. It is a rare condition Associated with other anatomically related defects such as a defective / absent external ear an under developed mandibular ramus or macrostomia. Unilateral condylar aplasia  Facial asymmetry A shift of the mandible towards the affected side occurs during opening In bilateral cases this shift is not present Treatment    Osteoplasty Orthodontic appliances Cosmetic surgery  in correcting facial deformity
  12. 12. 2. Hypoplasia of the mandibular condyle  Under development / defective formation of the mandibular condyle  Congenital hypoplasia    Idiopathic Characterized by uni / bilateral under development of the condyle Acquired hypoplasia May be due to any agent which interferes with the normal development of the condyle. Causes:  Forceps deliveries  External trauma  X-ray radiation  Infection   Cl/ft:     Condylar hypoplasia depends upon whether the disturbance has affected one or both condyles and upon the degree of malformation. Age of the patient at the time of involvement The duration of the injury and its severity Unilateral involvement is the most common clinical type
  13. 13. I. Developmental disturbances of the TMJ  Cl/ft   Limitation of lateral excursion on one side  Mandibular midline shift during opening and closing  The distortion of the mandible results in lack of downward and forward growth of the body of the mandible   Facial asymmetry Due to arrest of the chief growth center of the mandible i.e., condyle. Treatment & prognosis  Cartilage / bone transplants  Unilateral and bilateral osteotomy to improve the appearance of the patient with asymmetry and retrusion.
  14. 14. I. Developmental disturbances of the TMJ 3.Hyperplasia of the mandibular condyle Condylar hyperplasia is a rare unilateral enlargement of the condyle Causes: Obscure Sugg. Factors  Mild chronic inflammation which stimulates the growth of the condyle or adjacent tissue.   Cl/ft: patient is usually exhibit     A unilateral, slowly progressive elongation of the face with deviation of the chin away from the affected side. The enlarged condyle may be clinically evident The affected joint may or may not be painful A severe malocclusion is a usual sequela of the condition
  15. 15.
  16. 16.  R/F:    Condyle with an elongated neck and enlarged condylar head Scintigraphy using 99mTc-MDP used for assessing degree of bone activity in condylar hyperplasia. Treatment and prognosis    If growth is occurring  condylectomy If growth is ceased  orthognathic surgery is performed Resection of condyle restore normal occlusion.
  17. 17.
  18. 18. Developmental disturbance of TMJ Bifid condyle  Double headed mandibular condyle.  They have a medial and lateral head divided by A-P groove.  Some condyles may be divided into an anterior and posterior head. Etiology:  Uncertain.  A-P bifid condyle  traumatic in origin.  Mediolaterally divided condyles  trauma, abnormal muscle attachment, teratogenic agents.
  19. 19. Developmental disturbance of TMJ C/F:    Unilateral Asymptomatic Pop or click of TMJ R/F:  Bilobed appearance of the condylar head. Rx & Prognosis:  Asymptomatic  no treatment necessary.
  20. 20. II. Traumatic disturbances of the TMJ 1. Luxation and subluxation (complete & incomplete dislocation)  Dislocation of the TMJ ↓  when the head of the condyle moves anteriorly over the articular eminence into such a position that cannot be returned voluntarily to its normal position.  Luxation of the joint  complete dislocation while subluxation is a partial / incomplete dislocation  Luxation may be ‘acute’, due to a sudden traumatic injury resulting in the fracture of the condyle.  Yawning / having the mouth opened too widely.
  21. 21. II. Traumatic disturbances of the TMJ  Cl/ft:    Sudden locking and immobilization of the jaws when the mouth is open. Accompanied by prolonged spasmodic contraction of the temporal, internal pterygoid and masseter muscles with protrusion of the jaw. Treatment:  Relaxation of the muscles and then guiding the head of the condyle under the articular eminence into its normal position by an inferior and posterior pressure of the thumbs in the mandibular molar area.
  22. 22. II. Traumatic disturbances of the TMJ 2. Ankylosis (hypomobility)    Etiology    Most incapacitating of all diseases involving the TMJ. It involves fusion of head of the condyle to the temporal bone. Traumatic injuries Infection in and about the joint Straith & Lewis:         Abnormal intrauterine development Birth injury Trauma to the chin forcing the condyle against the glenoid fossa, particularly with bleeding into the joint space. Malunion of condylar fracture. Injuries associated with fracture of the molar zygomatic compound. Loss of tissues with scarring Congenital syphilis Primary inflammation of the joint
  23. 23. II. Traumatic disturbances of the TMJ  Straith & Lewis:      Inflammation of the joint secondary to a local inflammatory process. Ex. Otitis media; mastoiditis; osteomyelitis of the temporal bone / condyle. Inflammation of the joint secondary to a blood stream infection Ex: Septicemia Metastatic malignancies Inflammation secondary to radiation therapy. Cl/ft:     Occurs at any age Most cases occur before the age of 10 years Distribution is equal between the genders The patient may / may not be able to open his mouth to any appreciable extent, depending on the type of ankylosis
  24. 24. II. Traumatic disturbances of the TMJ  Ankylosis  Unilateral    Occurs at early age The chin is displaced laterally and backward on the affected side because of a failure of development of the mandible. Bilateral   In childhood results in underdevelopment of the lower portion of the face, a receding chin and micrognathia. The maxillary incisors often manifest overjet due to failure of this mandibular growth.
  25. 25. II. Traumatic disturbances of the TMJ  TMJ Ankylosis (depending on anatomic sites of ankylosis) Intra-articular ankylosis Extra-articular ankylosis Joint undergoes progressive Results in a “splinting” of the TMJ destruction of the meniscus by a fibrous or bony mass external Flattening of the mandibular fossa to the joint proper and. thickening of the head of the But movement is possible in this condyle & narrowing of the joint type space
  26. 26. II. Traumatic disturbances of the TMJ  R/Ft:   Reveals abnormal / irregular shape of the head of the condyle Treatment:   Surgical osteotomy / removal of section of bone below the condyle. Fibrous ankylosis can be treated by functional methods.
  27. 27. II. Traumatic disturbances of the TMJ 3. Injuries of the articular disk (meniscus)    Malocclusion The adaptation of the disk to the condyle is lost which results in disk derangement. Precipitating factors    Blow / fall Inflammatory condition such as Rheumatoid arthritis Cl/ft:     Common in females Young adults are more frequently affected. Pain, snapping or clicking and crepitation in the joint area. Transient / prolonged locking of the jaw may occur, when the mouth is closed 
  28. 28.
  29. 29. II. Traumatic disturbances of the TMJ  R/Ft:   Does not give any positive findings Treatment:   Immobilization of the jaws is necessary in cases of severe pain Menisectomy / surgical removal of the disk.
  30. 30. III. Fractures of the condyle Condylar fracture  Acute traumatic injury to the jaw  Limitation of motion, pain and swelling over the involved condyle  Deformity is noted upon palpation and loss of normal condylar excursion.  The fractured condyle fragment is frequently displaced anteriorly and medially into the infratemporal region because of the forward pull of the external pterygoid muscle and reduction of the fracture is often difficult because of this displacement.  Healing of such fracture without reduction results in loss of function, limitation of motion or any other complication.
  31. 31. IV. INFLAMMATORY DISTURBANCES OF THE TMJ  Arthritis / inflammation of the joints, is one of the most frequent pathological condition affecting the TMJ.  TMJ may suffer from any form of arthritis but there are 3 common types given by Mayne and Hatch.  Arthritis due to a specific infection.  Rheumatoid arthritis.  Osteoarthritis / degenerative joint disease.
  32. 32. 1. Arthritis due to a specific infection / infective arthritis: Septic arthritis of TMJ is uncommon ↓ Like Neisseria gonorrhea, str, staph. aureus, pneumococci, the tubercle bacilli, H. influenzae  Caused by direct spread of a local infection or blood stream / lymphatic metastasis. C/F:  Pt suffering from acute infection arthritis. C/o: Severe pain in the joint.  Extreme tenderness  Healing of this form of arthritis often results in ankylosis.
  33. 33. H-P features  There is a variable amount of destruction of the articular cartilage and articular disk.  The joint spaces become obliterated in the healing phase by the development of granulation tissue  Subsequently transforms into scar tissue. Rx:  Antibiotics – in the acute phase  Meniscetomy / condylectomy is advocated in the advanced cases.
  34. 34. IV. INFLAMMATORY DISTURBANCES OF THE TMJ 2) Rheumatoid arthritis  Is a chronic multisystem disease of unknown antigen triggers an autoimmune response in genetically susceptible individual.  Proinflammatory kinins and cytokines play important role in pathogenesis of rheumatoid arthritis.  TMJ involvement  20% C/F:  M:F 2:1  Rh. Arthritis early stages manifests  Slight fever.  Loss of weight  Fatigability.  Joints affected are swollen  Patient c/o pain and stiffness on movement of the jaw.  Involvement of TMJ may occur with the other joint lesions.  Ankylosis of the joint over a period of time.
  35. 35. H-P features:  The joints show edema and inflammation of the synovial tissues and diffuse infiltration of chronic inflammatory cells into the articular architecture.  With increase in bone resorption there is a destruction of articular surface of the condyle.  Invasion of the cartilage and its replacement by granulation tissue Rx & Prognosis:  No specific treatment for Rh. Arthritis.  Administrations of ACTH/ Cortisone.  Surgical intervention in the form of condylectomy may be necessary to regain movement.
  36. 36.
  37. 37. IV. INFLAMMATORY DISTURBANCES OF THE TMJ 3. Osteoarthritis (degenerative joint disease, hypertrophic arthritis).  Is most common type of arthritis associated with aging process. Etiology: unknown. C/F:  Signs and symptoms of an absent since it is not a weight bearing joint.  Pts. c/o of clicking and snapping in the TMJ due to atypical disk motion.
  38. 38. IV. INFLAMMATORY DISTURBANCES OF THE TMJ H-P features:  The cartilage cells often exhibit degeneration and areas of dystrophic calcification may occur and this can progress to actual ossification also there may be necrosis of the disk. Rx:  Condylectomy.
  39. 39. V. NEOPLASTIC DISTURBANCES OF THE TMJ       Neoplasms and tumor-like growths, benign and malignant, may involve the TMJ. It is very uncommon. Origin: Within the bone of the mandibular condyle. Joint capsule or articular disk. Chondromas, osteomas and osteochondromas are common benign tumors.
  40. 40. VI. EXTRA-ARTICULAR DISTURBANCES OF THE TMJ  A variety of extraarticular disturbances may manifest themselves clinically as TMJ problems.           Impacted molar teeth Sinusitis Middle ear disease Infratemporal cellulitis Impingement of coronoid process on the tendon of the temporal muscle. Neuritis of the 3rd division of the trigeminal nerve. Odontolgia. A foreign body in the infratemporal fossa. Overclosure of the mandible accompanied by severe dental attrition. Costen’s syndrome.
  41. 41. VII. TEMPOROMANDIBULAR JOINT SYNDROME (TM disorder)  TMJ syndrome or TMD is the most common cause of facial pain after toothache.  TMD can be classified broadly as:   1. TMD secondary to myofacial pain and dysfunction (MPD). TMD secondary to true articular disease MPD type forms the majority of the cases of TMD  ↓ and is associated pain without apparent destructive changes of the TMJ on x-ray.  bruxism and day time jaw clenching in a stressed and anxious person.
  43. 43. VII. TEMPOROMANDIBULAR JOINT SYNDROME (TM disorder) 2. True intra-articular disease :         Disk displacement disorder. Chronic recurrent dislocations. Degenerative joint disorders. Systemic arthritis conditions Ankylosis. Infection Neoplasms. Etiology:        Multifactorial and includes: Malocclusion. Jaw clenching. Bruxism. Personality disorders Increased pain sensitivity. Stress and anxiety.
  44. 44. VII. TEMPOROMANDIBULAR JOINT SYNDROME (TM disorder) C/F:    1. 2. 3. 4.     Affects young woman aged 20-40 yrs. M:F – 1:4. 4 cardinal signs and symptoms of the syndrome: Pain Muscle tenderness. Clicking / popping noise in the TMJ. Limitations of the jaw motion unilaterally / bilaterally with deviation on opening. The pain is usually periauricular. Associated with chewing and may radiate to head. May be unilateral or bilateral in MPD. But it is unilateral in TMD of articular origin.
  45. 45. In MPD the pain, bruxism, jaw clenching, stress and anxiety.  In TMD pain is associated with clicking, popping and snapping sounds.  Limited jaw opening due to pain / disk displacement.  TMD acts as a trigger in pt prone to headaches. Lab findings:        Blood examination. Blood count Rheumatoid factor ESR Antinuclear antibody. Uric acid
  46. 46.  Treatment & Prognosis: Self limiting. 2. Conservative treatment involving self care practices.  Rehabilitation aimed at eliminating muscle spasms.  Restoring correct coordination. 3. NSAIDs  Prognosis is good. 1.
  47. 47. Investigations  TMJ imaging is used as an additional diagnostic aid in cases of suspected pathology of    Morphology of bony components of joint Functional relationship b/w condyle and fossa Two dimensional imaging  Panoramic radiographs  Transcranial view  Transpharyngeal view  Transorbital view  Reverse Towne’s view  Submento-vertex (SMV) view  Conventional tomography  Arthrography
  48. 48. Investigations  Three dimensional imaging  Computed tomography (CT)  Magnetic resonance imaging (MRI)  Arthroscopy  Bone scan
  49. 49. Two dimensional imaging  Panoramic radiographs  Used as screening projection
  50. 50. Indications  Reserved for assessing  Gross changes in the condyles  Asymmetries  Extensive erosions  Large osteophytes  Fractures Disadvantages  No information about condylar position or function is provided  Osseous changes are obscured because of superimposition by the skull and zygomatic arch
  51. 51. Transcranial projection - modified Schuller method  Provides sagittal view of lateral aspects of condyle and temporal component Indication  Gross changes on the lateral aspect of joint  Displaced joint fractures  Range of motion (open view) 
  52. 52. Transpharyngeal projection  Provides sagittal view of the medial pole of the condyle Indications  To visualize gross erosive changes of the condyle
  53. 53. Transorbital view  Also known as Transmaxillary, antero posterior view  Provides an anterior view of the TMJ perpendicular to the transcranial and transpharyngeal views  Mainly for detection of condylar neck fractures Reverse Towne’s view   Similar to transorbital view Useful for viewing medial displacements of the condyle
  54. 54. Submentovertex (SMV) projection  Provides view of the base of the skull with condyles superimposed on the condylar neck and rami Conventional tomography  Provides the most definitive diagnostic information about the osseous structures of the TMJ  Provides visualization of anatomic stc’s free from superimposition
  55. 55. Arthrography      Provides information regarding soft tissue of the joint Technique – intra- articular administration of radio-opaque iodinated contrast agent is done under fluoroscopic guidance After both the joint spaces are filled with the the contrast agent the disk function is studied using fluoroscopy supplemented by tomography Adv – it is adv over MRI in identifying any perforations b/w the superior and inferior joint compartments Disadvs – 1. expensive 2. ptn may develop allergy to contrast medium 3. invasive
  56. 56. Three dimensional imaging  Computed tomography  Incorporates the principles of direct digital (computed) electronic imaging & cross sectional radiography (tomography)  Provides visualization in all 3 planes  Sagittal (lateral)  Coronal (frontal)  Axial
  57. 57. Advantages –  Reformatting of sequence of axial images into images of other planes or 3D images is possible  Complete elimination of superimposition  Intravenous contrast media can be used to differentiate one soft tissue type from another Disadvantages  Expensive  Requires trained personnel to obtain scans and interpret scans
  58. 58. CT in TMJ imaging  Used to visualize bony changes of the condyle and articular eminence
  59. 59. Magnetic resonance imaging (MRI)  It does not use ionising radiation (X-rays) but utilizes Hydrogen atoms in the body which react in a certain way when subjected to a magnetic field
  60. 60.      Used to image soft tissues of the TMJ to visualize Joint effusion Disk position Disk shape Inflammatory changes
  61. 61. Advantages  Offers best resolution of tissues of low inherent contrast  Multiplanar imaging is possible without re-orienting the ptn Disadvantages  Long imaging time  Cannot be used for ptn’s with pacemakers  The machine makes a tremendous amount of noise during a scan  Claustrophobic patients cannot be scanned
  62. 62. Arthroscopy  It is a surgical procedure used to visualize, diagnose & treat problems inside a joint Why is it necessary?  To confirm the pathology & make a final diagnosis which may be more accurate than through “open” surgery or from x-ray studies.
  63. 63. Bone scan / Radionuclide imaging  A radiolabeled material –Tc-pertechnetate 99m is injected into the blood stream & this concentrates in the area of rapid bone turnover  A gamma scintillating camera is used to image this.  Useful in determining a active (osteoarthritis)or dormant (osteoarthrosis) pathologic condition
  64. 64. References      Shafer’s Textbook of Oral Pathology. 5th edition. Neville: Oral & Maxillofacial Pathology. 2nd edition. Jaffery P. Okeson – Management of Temporomandibular disorders and occlusion. Martin S. Greenberg, Michael Glick – Burkit’s oral medicine and diagnosis. Franklin C.D.: Pathology of the temporomandibular joint. Current Diagnostic Pathology (2006): 12, 31-39.
  65. 65. Thank you For more details please visit