Degenerative joint disorders of TMJ

1. Degenerative joint
disorders of
Temporomandibular joint
Presented by- Dr Shibani Sarangi
Dept of Oral & Maxillofacial surgery
Postgradute IIIrd year

2. Definition
• Degenerative disease of the temporomandibular joint is the most common organic disease
of the joint and is the end result of many different insults to the joint surfaces.
-David A.Keith
• A chronic debilitating disease resulting in altered joint structure due to degradation and loss
of articular cartilage, along with changes in the subchondral bone and other soft tissues. DJD
is a frequent finding in the Temporomandibular joints (TMJs).
• It is a localized joint disease without systemic manifestations.

3. Osteoarthritis

4. Defination
• Arthrosis deformans
• Osteoarthritis is a non-inflammmatory
degenerative disease affecting the
articular surfaces which are
accompanied by remodeling of joint
surfaces.
• The process begins in loaded articular
cartilage, which thins and clefts
(fibrillation) and then breaks away
during joint activity. This leads to
sclerosis of underlying bone,
subcondylar cysts, and osteophyte
formation. (Ref:Int Dent J 1990;40:339)

5. Etiopathogenesis
• Osteoarthritis has a complex and
multifactorial etiology,Risk factors’ includes-
 Age
 Genetics
 Trauma
STRESS INTENSITY >FUNCTIONAL CAPACITY
 Disturbances of joint or muscle (joint
instability, inadequate muscle
strength/endurance, internal derangements,
discectomy, ligament laxity),
 Systemic conditions (generalized osteoarthritis,
infection and idiopathic degenerative process,
congenital and developmental abnormality)

6. Immune cells inflammatory response
cytokines chemokines
Activates complement system
MMPs and PGEs
degradation and abrasion of joint cartilage &
remodeling of the subchondral bone

7. Clinical
features
 Osteoarthritis can occur at any age,
although, it occurs with greater
frequency as age increases. Highest
prevelence between 40-65 yrs.
 May be unilateral / bilateral .
 Higher women predilection.
 Pain in the TM joint and muscules of
mastication
 Limitation in mandibular movements
 Joint noises and crepitation
 Morning stiffness for more than 30
mins

8. • In general, the natural course of TMJ osteoarthritis is favorable and can be divided into
three slow progressive phases, with periods of remission and cartilage regeneration.
- Early phase- evolution phase
May take on average 2.5–4 years
Associated with clicking sounds and intermittent locking
-Intermediate phase - associated with TMJ destruction
-Lasts on average 6 m-1 yr
- Spontaneous joint pain at rest or with function,
limitation in opening, and grating sounds .

9. • Late phase- no degenerative activity, and the joints are said to be stable or
in the ‘‘burnout phase’’
- lasts about 6 months, and it will eventually stabilize with time
- absence of joint pain, absence /presence of limitation,
absence / presence of grating sounds

10. Clinical
Laboratory
Evaluation
and Imaging
• Lab diagnosis-
Erythrocyte sedimentation rate (ESR) commonly used.
Elevation in ESR and C reactive protein is indicative of an
infectious or inflammatory etiology.
• Radiographic diagnosis-
• Early leisons- Subchondral bony sclerosis
Loss of density of subchondral bone at bony
articular surface
Rough wooly appearence with bone rarefaction
at articular surface
• Advanced leison-
Gross destruction of condyle & articular eminence
Reduction of joint spaces
-Osteophyte formation

12. TREATMENT PYRAMID
Temporomandibular Joint Osteoarthritis: Diagnosis and Long-Term Conservative Management: A Topic Review Indian
Prosthodont Soc (Jan-Mar 2014) 14(1):6–15

13. Treatment
• Non-pharmalogic-
Activity modification & habit modification-
 It includes patient instruction on soft diet, avoiding excessive mouth
opening, avoiding gum chewing.
 Auto-massaging may help in reducing pain and stiffness.
 Oral Appliance Therapy
 Anterior repositioning appliance

14. • Pharmacological-
 Pharmacological modalities of treatment includes
-Acetaminophen
-Cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal
anti-inflammatory drugs (NSAIDs)
-Topical NSAIDs and capsaicin
-Intra-articular injections of corticosteroids and hyaluronates,
glucosamine and/or chondroitin sulphate for symptom relief; glucosamine
- Sulphaste, chondroitin sulphate and diacerein
Temporomandibular Joint Osteoarthritis: Diagnosis and Long-Term Conservative Management: A Topic Review
Indian Prosthodont Soc (Jan-Mar 2014) 14(1):6–15

15. • Topicals
• Guidelines proposed by the American Academy of Orthopaedic Surgeons, European League Against
Rheumatism,Osteoarthritis Research Society International, and National Institute for Health and Clinical
Excellence
 Diclofenac sodium topical solution 1.5 % with dimethyl sulfoxide was also found
to be beneficial.
 Topical trolamine salicylate 0.5 %
• Intraarticular Injections, Arthrocentesis and Viscosupplementation-
 Intra-articular injection of local anesthetics and corticosteroids has also been
suggested following failure to oral medications.
 Methylpredinisolone and triamcinoloneacetonide 0.45% also been used.
Temporomandibular Joint Osteoarthritis: Diagnosis and Long-Term Conservative Management: A Topic Review Indian
Prosthodont Soc (Jan-Mar 2014) 14(1):6–15

16. • Viscosupplementation -
• They are effective in primary and secondary osteoarthritis
• Viscosupplementation has analgesic,anti inflammatory, anabolic, and
chondroprotective effects
• It is a disease modifying agent as well as provides pain relief.

17. Viscosupplementation for Osteoarthritis of the Knee: Strategies to Improve Patient Outcomes; Medscape
Tuesday, July 16, 2019

18. Surgery
• Include arthroplasty procedures such as condylotomy,
• Autogenous disc replacement and total joint replacement
procedures

19. RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS

20. • Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune inflammatory
disorder that is characterized by joint inflammation, erosive properties and
symmetric multiple joint involvement
• Usually involves peripheral joints with a symmetric distribution and shows a
progressive course.
• CLINICAL FEATURES & R/G FEATURES-
• Intermittent preauricular pain,swelling and progressive limitations in jaw
movements.
• Generally associated with fever,malaise and anorexia,
• TMJ is seldom the first joint involved. Often associated with Caput Ulna
syndrome

21. • Early stage- Limitations upto soft tissue Hence,radiographic changes in RA
generally do not appear in the early phase of the disease.
• Late stage- Erosion of joint ,subchondral cysts & joint space reduction
and bony destruction
-Osteoporosis

22. Narrowing of the articular space and
erosions on superior head of the
condyle
Rheumatoid arthritis affecting temporomandibular joint; Contemp Clin Dent. 2015 Jan-Mar; 6(1): 124–127.

24. Larsen’s radiographic scoring for RA
 0: Normal
 I: Slight abnormality, joint space is slight narrow,
 II: Early abnormality, joint space is slightly narrow, with erosion,
 III-moderate destruction, joint space is narrow and eroded, IV-severe destruction, joint space is
narrow, with erosions and bone deformity,
 V-mutilating abnormality, disappearance of joint space, with erosion and bone deformity
A novel radiographic scoring system for growth abnormalities and structural change in children with juvenile idiopathic
arthritis of the hip: Pediatric Radiology.10024_421

28. Management
• Medical therapy
• These include reassurance; jaw rest with a soft diet; avoidance of wide mouth opening;
physiotherapy; non-steroidal anti-inflammatory drugs (NSAIDs), which can be prescribed
topically; and soft occlusal splints made by the dentist
• Disease-modifying antirheumatic drugs (DMARDs)
• Patients with mild disease and normal radiographic findings can begin treatment with
Hydroxychloroquine Sulfasalazine, or Minocycline, although Methotrexate also is an option.
• Patients with more severe disease or radiographic changes should begin treatment with
Methotrexate.
• If symptoms are not adequately controlled, Leflunomide, Azathioprine, or combination therapy
(methotrexate plus one of the newer agents) may be considered.

29. • NSAIDS-
They do not alter the disease course, they should not be used alone. Patients with
rheumatoid arthritis are almost two times more likely to have serious complications
from NSAID use than patients with osteoarthritis, and they should be observed closely
for symptoms of gastrointestinal side effects
• GLUCOCORTICOIDS -
• The American College of Rheumatology (ACR) guidelines recommend that patients
being treated with
Glucocorticoids take 1,500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the
management of rheumatoid arthritis: 2002 update. Arthritis Rheum 2002;46:328-46.

30.  Local anesthetic and steroid injections
• Pain emanating from the TMJ can be confirmed, and temporarily relieved, by
infiltration of local anesthetic (lignocaine 1% or 2%) into the joint space.
Resolution of the pain after 10 min establishes an intra-articular etiology
rather than a muscular source.
Management of the temporomandibular joint in inflammatory arthritis: Involvement of surgical procedures:Eur J
Rheumatol. 2017 Jun; 4(2): 151–156.

31.  Arthrocentesis-
 Arthros; a joint , kentesis ; puncture
 Arthrocentesis of the temporomandibular joint refers to lavage of the upper joint space,
hydraulic pressure and manipulation to release adhesions of the “anchored disc phenomenon”
and improve motion.
 Indications- for patients with
 anterior disc displacement with and without reduction,
 disc adhesions
 synovitis/capsulitis,
 palliation for acute degenerative rheumatoid arthritis
 Hemarthrosis due to recent trauma

32. TECHNIQUE
The technique starts by anaesthetizing the
auriculotemporal nerve followed by posterior
deep temporal and masseter nerves. This
provides optimal region analgesia, preventing
the need for sedation. A straight line is drawn
from the medial portion of the ear tragus to the
lateral corner of the eye. In this line, two needle
insertion points are marked. The first, more
posterior point will be at a distance of 10 mm
from the tragus and 2 mm below the
cantotragal line. This is the approximate area of
the maximum concavity of the glenoid fossa.
The distance is about 25mm from skin to the
centre of the joint space.

33.  Types of technique-
• Single needle technique
• Double needle technique

34. Mode of action
 Arthrocentesis changes synovial fluid viscosity, thus contributing for the translation of the disc
and mandible head complex
 In addition, when performed under pressure and combined with shearing forces generated by
jaw manipulation it could break down early adhesions, thus improving mouth opening.
 Pain is decreased or eliminated possibly due to the wash-out of chemical pro- inflammatory
mediators, associated to the direct action of instilled drugs on intracapsular pain receptors.

35.  Open joint surgery
• Prior to the widespread use of arthroscopy and arthrocentesis, the management of TMJ
problems unresponsive to simple treatments was done using open surgery.
• Synovectomy is a high-risk procedure, it was found that it successfully treated pain and
restricted opening in patients with RA affecting the TMJ, but was normally combined
with discectomy that probably accounted for the majority of symptomatic relief .
• Other procedures eminoplasty, eminectomy, disc plication, discectomy, and
adhesiolysis

36. Psoriatic Arthritis

37. • Psoriatic arthritis (PsA) is a form of inflammatory arthritis that can affect some
of the millions of people who have psoriasis. Psoriasis is a skin disease that
causes a red, scaly rash, most often on your elbows, knees, ankles, feet, hands,
and other areas.
• It is autoimmune mediated disorder
• Characterisied by erosion of joint ,asymmetric polyarthritis and a negative RH
factor.
MALE > FEMALE
• Clinically it manifests with pain, tenderness, limitations of motions and swelling.

38. • TYPES-
 Oligoarticular: Usually a milder type that affects four or fewer joints
 Polyarticular: A more severe type that affects four or more joints
 Radiographic features-
 R/g characterisied with blurring of subchondral bone margins,subchondral
sclerosis, bony erosions and progressive narrowing of joint spaces
 Rarely ankylosis may develop.

39. • MANAGEMENT-
• Main goal is maintainence of functional posture associated with suppression of
pain and inflammation.
• Medicaments in use Phenylbutazone & Indomethacin.
• Intra-articular injection s with Hyaluronic acid

40. GOUT

41. • Gout is a benign disease characterized by a deposition of monosodium urate
(MSU) crystals in the joints or soft tissue.
• It is classified as a metabolic arthritis. Gouty arthritis rarely affects the head and
neck region, especially the temporomandibular joint (TMJ).
• Clinical manifestations-
 Arthropathy in the TMJ may be subtle in the initial stages, with limited jaw
opening, mild pain and joint sounds
 Joint area appears reddened ,warm ,swollen and tender

42. • Laboratory tests-
• The American College of Rheumatology has proposed that the detection of MSU crystals in
synovial fluid is a pathognomonic laboratory finding for the diagnosis of this disease
• MSU crystals are known to be deposited in the synovium and periarticular structures, causing
joint space narrowing, bony erosion, subchondral bone cysts, reactive sclerosis, soft-tissue
masses, nephrolithiasis and urate nephropathy
 Other tests-
 BUN:creatinine ratio .
 Serum uric acid
 ESR

44. CONDYLAR RESORPTION

45. • Bone loss at the mandibular condyle has been described as a result of orthognathic surgery,
systemic and local arthritides, post-traumatic remodeling, and/or hormonal imbalance.
• Osseous condylar resorption that occurs without obvious cause is termed idiopathic condylar
resorption (ICR). Condylar resorption can be aggressive (months) or slow (years).
• The signs of condylar resorption are:
• Facial imbalance (receding chin),
• Smaller airway (snoring, apnea) and
• Bite disturbances (anterior open bite, posterior tooth wear and muscle pain)
• Other causes-
• Systemic sclerosis
• Fanconi syndrome.

46. DIAGNOSIS -
 99mTechnetium-methylene diphosphonate (99mTC-MDP)-
Amount of radiation involved, which is approximately 4–6 mSv.
 CBCTs and MRIs can be used to assess whether the ICR is active or arrested.
 MANAGEMENT Treatment for ICR is generally done for one of two reasons. If done during active
ICR, it is usually for the purpose of halting the progression of ICR. If done after ICR has stopped, it
is usually to restore occlusion and esthetics. Treatment options range from no treatment to
condylar replacement and osteotomy. Being a rare and idiopathic condition, there are insufficient
data in the literature to make evidence-based recommendations for treatment.

47. MANAGEMENT
Treatment for ICR is generally done for one of two reasons. ICR, it is usually for the purpose of
halting the progression of ICR. -
 If done stopped, it is usually to restoreduring active
 If done after ICR has occlusion and esthetics.
• Treatments performed to arrest idiopathic condylar resorption-
 Splint
 Removal of hyperplastic synovium
 Condylectomy and costochondral graft.
Young A. Idiopathic condylar resorption: The current understanding in diagnosis and treatment. J Indian Prosthodont Soc 2017;17:128-35.

48. TRAUMATIC ARTHRITIS

49. • Post-traumatic arthritis (PTA) develops after an acute direct trauma to the joints.
• It can lead to sudden loss of subarticular bone, that leads to occlusal
discrepancies.

51. SUPPORTIVE THERAPY
• Soft diet with minimal jaw movement is advised to aptient.
• NSAIDS
• Moist heat therapy (7-10 days)
• Secondary causes elimination- Bruxism
• Occlusal splint therapy

52. DIAGNOSTIC IMAGING OF THE
TEMPOROMANDIBULAR JOINT

53.  PLAIN FILM, TOMOGRAMS, AND PANORAMIC RADIOGRAPHY
• Initial screening for gross osseous abnormalities can be performed with standard
Transcranial (lateral oblique) views.
• The transcranial perspective provides a global view of gross bony architecture of the articular surfaces.
 Panoramic radiographs
• Open and closed-mouth tomographic views can provide valuable information with regard to
condylar translation

54. Expected contours of lateral condylar tomograms in varying stages
of degenerative joint disease
Normal
Minimal
Severe

55. Temporomandibular joint-tomographic series depicting excellent osseous detail with 5 mm cuts.
STAGE 1 STAGE 2(Bird beaking)

56. BONE SCANS
• Radionuclide imaging of the temporomandibular joint can provide information about the
dynamics of bone metabolism in a variety of pathologic states
• .
• A scintillation camera can be used for both dynamic and static imaging in which a gamma
detector quantifies gamma ray emissions from injected isotopes such as Technetium 99.
• Three phases of 99mTc bone scans-
1st phase –Flow study(3-4 secs)
2nd phase- Blood pool study (1-2 mins)
3rd phase- Delayed phase(2-4 hrs)
• Diagnostic importance- Occult osteomyelitis
Condylar hyperplasia

57. ARTHROGRAPHY
• The usual technique involves injection of a water-soluble, iodinated contrast material into the
inferior joint space under fluoroscopy.
• Under fluoroscopic guidance, a 23-gauge needle is directed into the posterior inferior joint space.
When the tip of the needle encounters the condyle, 0.2 to 0.4 ml of contrast material is injected
into the posterior recess of the inferior joint space.
• Alter confirming that the contrast is in the proper space, the clinician instructs the patient to
open and close the mouth, and dynamic videotape images are recorded during opening and
closing.

58.  Disadvantages of Arthrography-
• Invasiveness
• Pain (intraoperative or postoperative)
• Risk of infection
• Potential damage to disk, capsule, and fibrocartilage
• Allergy to contrast material (or local anesthetic)

59.  COMPUTERIZED TOMOGRAPHY
• Computerized tomography (CT) of the temporomandibular joints is currently the best method for
assessing bony pathologic conditions
• Axial and coronal views are
excellent for assessing normal
and abnormal osseous anatomy

60. • MAGNETIC RESONANCE IMAGING
• Magnetic resonance (MR) images can be obtained in the sagittal, axial,
and coronal planes. Slice thickness usually varies between 3 and 10 mm.
• Thinner sections result in improved image quality because "volume averaging"
of the structures is reduced.
• In most normal scanning sequences,

61. CBCT
• It came into existence in the year 1982
• CBCT plays an important role in diagnosing early stages of juvenile idiopathic arthritis (JIA) in
children which, when undetected, can damage facial development and cause growth alterations.
• CBCT has an advantage over other imaging modalities due to the low patient radiation exposure.

62. SURGICAL PROCEDURES

63. Surgical decision making in Temporomandibular surgery
Degenerative joint disease
Arthroplasty with diskectomy
Condyletomy/ High Condylar shave
Joint replacement
Alloplastic
Autogenous
•Costochondral
•Sternoclavicular
•Ileum
•Calvarial
Autogenous interpositional
graft
Temporalis muscule flap
Silastic implants

64. CONDYLOTOMY
• It is a closed section of Mandibular ramus developed by Ward as a modification of Kostecka’s
operation.
THE APPLIED ANATOMY OF CLOSED CONDYLOTOMY, British Journal of Oral Surgery 15 (1977-78) 245-252

65. Radiographs of a left ramus, demonstrating the final position of the
Gigli saw, just lateral to the divided condylar neck.
THE APPLIED ANATOMY OF CLOSED CONDYLOTOMY, British Journal of Oral Surgery 15 (1977-78) 245-252

66. CONDYLECTOMY
• As an isolated procedure for joint pain ad for TMJ ankylosis surgery.

67. q

68. HIGH CONDYLAR SHAVE
• It consists of limited removal of damaged articular surface of condyle that maintains the height
of ramus , the meniscus and surrounding tissues including lateral pterygoid muscule attachment.
TECHNIQUE-

71. EMINOPLASTY/EMINECTOMY
• Eminoplasty-eminenectomy can be an important adjunct in the surgical correction of internal
derangements, or it can be used alone for treatment of hypermobility.
• The eminence must be recontoured as far medially as possible to ensure that adequate bone is
removed.

73. MENISCECTOMY
• Meniscectomy can be performed when the disk is irreparable. In the past, some surgeons
favored meniscectomy for anterior displacement.
• Meniscectomy is removal of the central avascular portion of the disk and the area of perforation
through the posterior ligament, where the tissues may be irreparably damaged.
• Crepitus is also a common finding following menisectomy, to overcome this temporary silicone
"pull-out“ implants are placed.

74. GRAFTS IN TMJ RECONSTRUCTION

75. AUTOGENEOUS MATERIALS
Costochondral graft
Sternoclavicular graft

76. ALLOPLASTIC GRAFTS
Salvage Procedures(Total temporomandibular joint replacement surgery )
• It was developed during the 19th century, with current prostheses modified from those produced
in the 1960s by Christensen.
• Currently, there are two systems The first is the
1)TMJ Concepts (TMJ Concepts; Ventura, CA, USA)
2) The second system is the Biomet (Biomet; Jacksonville, FL, USA)

77. TMJ PROSTHESIS

78. Traditional prosthesis systems
 1)Christensen TMJ prosthesis
• The Christensen Tmj fossa eminence prosthesis (FEP) is
designed to be used alone as a partial joint.
• The condylar prosthesis is always used in conjuction with
a FEP & constitutes a total joint replacement (TJR).
• It consists of cobalt-chromium (Co-Cr) alloy condylar prosthesis,
which had a molded PMMA head.

79. Kent- Vitek prosthesis
• In the early 1970s Kent developed a glenoid fossa implant (VK-1)
• Original VK-1 has articulating surface composed of PTFE
• The fossa was revised and called the VK-2 fossa & its articulating
surface was composed of UHM-WPE

80. Biomet SYS
Formerly known as Lorenz prosthesis.
The main diffrentiating feature is fossa component
is made of all high Mw Polyethylene without Titanium
mesh fitting surface.
This prosthesis requires Eminectomy to be
performed, to allow press fit of prosthesis and permit
to be be screwed in place.

81. REFERENCES
 Surgery of the Temporomandibular joint; Keith
 Management of Temporomandibular disorders and occlusion; Jeffrey P Okeson
 Operative Oral and maxillofacial surgery ; John D Langdon
 Color Atlas of Temporomandibular joint Surgery;Peter D Quinn