Disc interfernece disorder/endodontic courses
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Disc interfernece disorder/endodontic courses
- 1. DISC – INTERFERENCE DISORDERS INDIAN DENTAL ACADEMY Leader in continuing Dental Education www.indiandentalacademy.com
- 2. CLASSIFICATION 1. Class I interference 2. Class II interference 3. Class III interference - Excessive passive interarticular pressure - Structural irregularity - Non inflammatory degenerative joint disease - Internal derangement www.indiandentalacademy.com
- 3. • Disc condyle adhesions • Damaged articular disc • Displaced articular disc • Detached superior retrodiscal lamina 4. Class IV interference (Hypermobile subluxation) 5. Class V interference (spontaneous anterior dislocation) www.indiandentalacademy.com
- 4. • Rasmussen (J Dent 1981)reported that such disorders developed through 3 stages: Stage I Stage II Stage III www.indiandentalacademy.com
- 5. CLASS I INTERFERENCE • It occurs in closed position the joint as a result of maximum intercuspation of teeth. • The basic cause is chronic occlusal disharmony. • Symptoms- 1. sensation of tightness or movement 2.frequently accompained by sharp pain 3.Discrete clicking sound just as biting pressure is released. www.indiandentalacademy.com
- 6. • Etiologic factor is reversible • Diagnotic criteria: - Pain if any is intermittent ,noninflammatory. -Binding or rubbing sensation with clenching. -Discrete click may be heard especially as biting pressure is released. -Prevented by a seperator. www.indiandentalacademy.com
- 7. • Differential diagnosis -Lateral pterygoid muscle spasm -Acute retrodiscitis. www.indiandentalacademy.com
- 8. • Treatment -Temporary occlusion correcting splint. -Correction of occlusal disharmony. www.indiandentalacademy.com
- 9. CLASS II INTERFERENCE • Typical symptoms consists of an initial sensation of joint “sticking,” followed by a discrete click ,which is accompained by momentary discomfort. www.indiandentalacademy.com
- 10. CAUSES • Occlusal disharmony • Lack of firm occlusal contact • Trauma sustained with teeth occluded • Habitual use of excessive biting force • Bruxism. www.indiandentalacademy.com
- 11. DIAGNOSTIC CRITERIA • Trauma sustained with teeth in occlusion, chipped teeth, habitual hard chewing, day time clenching habits, noctural bruxism. • Pain if any, is intemittent noninflammatory, in conjunction with opening click. • No restricted range of motion and malocclusion. www.indiandentalacademy.com
- 12. DIFFERENTIAL DIAGNOSIS • Class II interference disorders should be differentiated from class III interference disorders. www.indiandentalacademy.com
- 13. TREATMENT • Elimination of etiologic factors • Occlusal splint can be used, it must be used 24 hrs a day for 6 months or longer. • Bruxism should be controlled • Dental restorations and partial dentures. www.indiandentalacademy.com
- 14. CLASS III INTERFERENCE DISORDERS • Disc interference symptoms during normal translatory cycles occur as a result of 4 conditions. 1.Excessive passive interarticular pressure. 2.Structural irregularity in the temporal articular surface. www.indiandentalacademy.com
- 15. 3. Non inflammatory degenerative change in the condylar or temporal articular surface. 4. Derangement of structures that comprise the disc-condyle complex. www.indiandentalacademy.com
- 16. EXCESSIVE PASSIVE INTERARTICULAR PRESSURE • It is the pressure that is exerted by muscle tonus. • It is increased by emotional tension and by spasm of elevator muscles. • Disc interference due to this cause may show sudden onset, variability and periodicity. www.indiandentalacademy.com
- 17. • Pain and acute malocclusion absent. • Catching sensations and discrete clicking during opening, associated with irregular movements. • DD: Masticatory muscle spasm Internal derangement disorders. www.indiandentalacademy.com
- 18. TREATMENT • Reduce emotional tension • Counselling and medical therapy. • Relaxation therapy • Soft diet, reduce jaw movement. • Occlusal splint • Biofeedback training. www.indiandentalacademy.com
- 19. STRUCTURAL IRREGULARITY OF TEMPORAL SURFACE. • Irregularity along the articular eminence ,sufficient to cause catching of the articular disc. • Causes: Developmental anamolies Growth aberrations Trauma Abusive use, mannerisms, chronic occlusal disharmony . www.indiandentalacademy.com
- 20. • Diagnosis: -History reveals chronicity, sameness, slow change, may be episodial. - Catching sensations and discrete clicking during opening. - No pain and acute malocclusion. - D/D: Class II interference disorder Class III excessive passive inter articular pressure, displaced disc disorder.www.indiandentalacademy.com
- 21. TREATMENT • Jaw use should be modified by habit training. • Habit training should be used to find and develop a purposely deviated path of opening – closing that evert interference. • If condition becomes intolerable than eminectomy. www.indiandentalacademy.com
- 22. NON INFLAMMATORY DEGENERATIVE JOINT DISEASE • Degeneration of the condylar surface causes crepitus and articular eminence causes noises during translatory cycles. • Diagnosis: -Noisy irregular translatory movements. (grating noise) DD: Other class III interference disorders. Inflammatory degenerative arthritis. www.indiandentalacademy.com
- 23. TREATMENT 1. Elimination of all abusive joint use. 2. Control bruxism 3. Occlusal correction www.indiandentalacademy.com
- 24. INTERNAL DERANGEMENT • Wilkies staging classification for internal derangement. 1. Early stage 2. Early/ Intermediate stage 3. Intermediate stage 4. Intermediate/ Late stage 5. Late stage www.indiandentalacademy.com
- 26. DISC-CONDYLE ADHESIONS • Due to hemarthrosis, induced by trauma or joint surgery. • Rough, irregular, noisy, skidding movements. • D/D: class IV interference disorders (hypermobile joint) • Rx, if symptoms become intolerable, surgery is required (arthroscopic surgery, high condylectomy, discectomy) www.indiandentalacademy.com
- 28. DAMAGED ARTICULAR DISC • Roughening of superior surface • Grating noise • Continuous thinning causes perforation • Thinning also predisposes disc fracture. • Seperated disc fragments leads to malocclusion. www.indiandentalacademy.com
- 29. • D/D: Inflammatory degenerative disorders. • If condition becomes intolerable, surgery may be required (discectomy). www.indiandentalacademy.com
- 30. DISPLACED ARTICULAR DISC • Functional displacements • Functional dislocations www.indiandentalacademy.com
- 32. RECIPROCAL CLICK Farrar WB et al, Ala Dent Assoc 1979 www.indiandentalacademy.com
- 36. CLOSED LOCK Roberts CA et al.Oral Surg 1985 www.indiandentalacademy.com
- 37. Treatment for displaced – dislocated disorders • Correction of etiologic occlusal disharmony. • Soft diet, restricted movements. • Disc excision • Condylectomy • Subcondylar osteotomy • Discoplasty, discectomy – www.indiandentalacademy.com
- 38. DETACHED SUPERIOR RETRODISCAL LAMINA • History reveals acute trauma. • Noisy , irregular movements in forward phase of translatory cycle. • No pain ,restricted range of motion, acute malocclusion. • D/D: Interference due to disc- condyle adhesions, Class IV hypermobile subluxation disorders. www.indiandentalacademy.com
- 39. • Treatment: - Surgical intervention is required if dislocation occurs. - Reduction and discoplasty ,if disc is not deformed. - Discectomy www.indiandentalacademy.com
- 41. SUBLUXATION • Also referred as hypermobility • As mouth is opened wide, momentary pause occurs followed by sudden jump / leap to maximal open position • Not associated with clicking • Preauricular depression seen on maximal opening www.indiandentalacademy.com
- 42. • ETIOLOGY: – Not pathologic – Due to articular eminence with short steep posterior slope & longer flatter anterior slope, may be due to erosion – Ligament laxity – Capsular flaccidity • In subluxating joint maximum rotational movement of disc is reached before translation of condyle. www.indiandentalacademy.com
- 43. • MANAGEMENT: – Supportive therapy: • Patient education regarding cause of symptoms • Voluntary restriction of excessive mouth opening • IMF – Definitive therapy: • Aggressive therapy generally not needed. • Where conservative therapy fails Surgical alteration of joint is needed (EMINECTOMY)www.indiandentalacademy.com
- 45. CLASS V INTERFERENCE DISORDERS - Spontaneous Dislocation (open lock) www.indiandentalacademy.com
- 47. • SPONTANEOUS DISLOCATION • Also called open lock • Mouth opened beyond normal limit resulting into dislocation • Patient unable to close jaw • Can occur in all joints but increased tendency in patients with subluxatio • May be unilateral / bilateral www.indiandentalacademy.com
- 50. • Etiology of acute dislocation: – Iatrogenic causes – excessive force during dental treatment – Excessive jaw manipulation under GA – Post – trauma – Excessive wide yawning / laughing – wide mouth opening – Predisposed by: • Laxity of ligaments, capsule, form of articular surfaces – flat eminence / shallow fossa. Premature contraction of superior lateral pterygoid muscle www.indiandentalacademy.com
- 51. • Clinical features: – Symptoms: • Pain, inability to close mouth • Difficulty in speech, mastication • Salivary drooling • Deviation of chin in unilateral cases – Signs: • Anterior open bite, gagging of posteriors • Lateral cross bite in unilateral cases • Protruding chin in bilateral cases • Tenderness in temporal region • Hollowness of preauricular areawww.indiandentalacademy.com
- 53. – Analgesics / anti-inflammatory drugs – Rest the joint / restrict joint movements – Avoid hard food – Immobilization. www.indiandentalacademy.com
- 54. • Recurrent / habitual dislocation: – Recurrent open lock of jaw – Distressing to patient • Management: – Prevention: – Conservative: • Botulinum toxin injection in inferior head of Lateral Pterygoid muscle – Surgical • Eminectomy www.indiandentalacademy.com
- 57. SURGICAL PROCEDURES • Arthrocentesis and lavage • Disc repositioning procedures. -Disc repositioning and discoplasty. -Disk repositioning and arthroplasty. • Repair of perforated posterior attachment. • Arthrotomy with disc repair - Plication - Bilaminar flap repair www.indiandentalacademy.com
- 58. • Disc – removal procedure - Partial discectomy - Total discectomy - Discectomy without replacement • Arthrotomy with discectomy and autologus graft disc replacement -Dermis -Auricular cartilage www.indiandentalacademy.com
- 59. • Arthrotomy with disectomy and autologus flap reconstruction. • Arthrotomy with discectomy and allopastic disc replacement. www.indiandentalacademy.com
- 60. ARTHROCENTESIS: • Includes lavage of the upper joint cavity • Improves disc mobility & eliminates joint inflammation & pain • Indications: – Patients not managed by conservative approach: medication, splint, physiotherapy – Patients with disc dysfunction, hypomobility, hypermobility, osteoarthritis www.indiandentalacademy.com
- 61. DISK REPOSITIONING PROCEDURE • Disk plication • Full thickness excision of wedge shaped tissue of posterior portion • Partial thickness excision of superior retrodiskal lamina www.indiandentalacademy.com
- 62. DISK PLICATION • Disk repositioning is achieved by plication of posterior attachment • Disk is sutured to lateral capsular ligament www.indiandentalacademy.com
- 63. Partial thickness excision of superior retrodiskal lamina • Partial thickness excision of superior lamina of retrodiskal tissue & posterior attachment are removed • Lateroposterior tissues are approximated • Inferior joint space is not violated www.indiandentalacademy.com
- 64. Full thickness excision of superior retrodiskal lamina • Full thickness wedge shaped portion of posterior attachment is removed and lateroposterior tissues are approximated www.indiandentalacademy.com
- 65. DISC REPOSITIONING AND ARTHROPLASTY • Arthroplasty reduces the amount of posterolateral repositioning required and therefore permits repositioning of an atrophic disc. www.indiandentalacademy.com
- 66. Disc repositioning with arthroplasty according to Walker and Kalamchi www.indiandentalacademy.com
- 67. REPAIR OF PERFORATED POSTERIOR ATTACHMENT www.indiandentalacademy.com
- 68. Management of large perforations with grafts. www.indiandentalacademy.com
- 69. DISC –REMOVAL PROCEDURES Partial discectomy To correct partial reducing disc displacement. “Disc reshaping” (JOMS 2003) Kondoh T, Hamada Y, Kamei K, Seto K. www.indiandentalacademy.com
- 70. TOTAL DISCECTOMY • Remolded posterior attachment and entire disc are excised. • Indicated in situations for which disc repositioning is not possible b/c of - Disc atrophy - Disc deformation - Severe degeneration of disc. www.indiandentalacademy.com
- 71. DISC REPLACEMENTS • Inperpositional material was believed to decrease joint noises by dissipiating loading forces on osseous surfaces. • Advanteges: 1. Reducing adhesions 2. Protecting articular surfaces 3. Diminishing pain and 4. Post diskectomy joint noise www.indiandentalacademy.com
- 72. • Dermal graft • Temporalis muscle • Autogenous fascia • Autogenous conchal cartilage • Silicone elastomer • Composite of polytetrafluoroethylene www.indiandentalacademy.com
- 73. REMOVAL OF MECHANICAL OBSTRUCTION • Surgical removal of obstacles which block / restrict the condyle from returning to its normal position in glenoid fossa. • Meniscectomy • Condylectomy & condylotomy • Eminectomy www.indiandentalacademy.com
- 74. MENISCECTOMY • Involves removal of torn / perforated meniscus Torn meniscuswww.indiandentalacademy.com
- 76. BIBLIOGRAPHY 1. Peterson’s : Principle of Oral and maxillofacial surgery. 2. Jeffrey.P.Okeson: Management of TMJ disorders and occlusion 3. Welden E.Bell: TMJ disorders 4. Raymond J.Fonseca: TMJ Disorders 5. Peter D. Quinn: Color atlas ofTMJ surgery 6. OMFS CLINICS of North America: Modern surgical management of the TMJ. www.indiandentalacademy.com
- 78. CLASSIFICATION A. Synovitis and capsulitis B. Retrodiscitis C. Inflammatory arthritis - Degenerative arthritis - Traumatic arthritis - Infectious arthritis - Rheumatoid arthritis - Hyperuricemia www.indiandentalacademy.com
- 79. SYNOVITIS AND CAPSULITIS • Capsular pain results from inflammation of the synovial and fibrous capsules, which is referred to as synovitis and capsulitis. • Pain occurs when inflamed capsule is stretched by translatory movement of condyle. www.indiandentalacademy.com
- 80. • Synovitis results from - Localized trauma - Abusive use - Toxemias - Specific infection - As an allergic response. www.indiandentalacademy.com
- 81. • Capsulitis may result from - Acute trauma - Intrinsic strains that injure capsular ligament. - Excessive mandibular movements - Abusive joint hypermobility. www.indiandentalacademy.com
- 82. • It is difficult , and indeed clinically impractical ,to distinguish between synovitis and capsulitis. • Capsulitis ---- Capsular fibrosis--- Restricted outer range of condylar movements. www.indiandentalacademy.com
- 83. Differential diagnosis Capsular inflammation should be differentaited from: 1. Pain in deep masseter muscle 2. Painful disc – interference disorders 3. Retrodiscitis 4. Inflammatory arthritis www.indiandentalacademy.com
- 84. Therapy for capsulitis • Restriction of condylar movements • Deep heat therapy using diathermy or ultrasound. • Anti-inflammatory drugs • Inj of corticosteroids. • Occlusal splints. • Antibiotics. www.indiandentalacademy.com
Editor's Notes
- It designates all the non inflammatory disorders of the TM joint in which the articular disc is chiefly responsible for the symptoms. This group includes particularly the noisy, clicking, popping joints, with or without a component of pain. Internal derangements is not synonymous with disc interference disorders. Disc interference predisposes to degenerative change in the joint.
- 4 year initial period of clicking and locking b.1 yr intermediate stage of arthralgia & restricted range of motion . C .a final stage of about 6 months with crepitation and restricted movements.
- The class I interference implies the magnitude required for the displacement of condyle disc complex after achieveing maximum intercuspation.
- If such disharmony has been created recently ,as with changes in dentition from trauma , extraction of posterior teeth , or dental treatment ,an acute muscle disorder is most likely to occur. any chronic occluisal disharmony activated by bruxism.
- This condition is due to condylar displacement when teeth are clenched, and only the elimination of the disharmony that causes such displacement is corrective. This condition is due to occlusal disharmony and is correctable by occlusal therapy.
- Symptoms of class II interference occurs as the mouth is opened immediately following maximum intercuspation. The rest of the translatory cycle is normal and the symptoms do not recur unless the teeth are again brought firmly into maximum intercuspation.
- Class II interference places considerable strain on the articular disc and its collateral ligaments . Therefore it predisposes to class III interference disorders if disc contour is lost and the ligament undergo detoriation and elongation.
- Symptoms of class III interference occur during the course of normal translatory cycles .It Results from catching of articular disc between condyle and eminence.
- Biofeed back technique incorporates the use of EMG and skin temperature to measure the patients physiologic function .The information is then conveyed back to the pateints by a meter or sound .pt can gauge their level of relaxation and measure progress accordingly.
- It is based on the clinical ,radiologic and anatomic divisions. Early stage – clinically there is early opening reciprocal clicking ,no pain. Rgh slight forwaRD displacement ,anatomocally, excellent anatomic form with slight anterior displacement. Early intermediate stage- one or more episodes of pain ,transient catching or locking. rgh slight thickening of posterior edge. anatomically ant disc displacement Intermediate stage – multiple episodes of pain .locking, rgh ant disc displacement with significant deformity , anatomically ,marked anatomic disc deformity with ant displacement, no hard tissue injury Intermediate/late stage- slight increase in severity, rgh-flattening of eminence, deformed condylar head. anatomically hard tissue degenerative remodelling of both bearing surfaces. Late stage-crepitus, scraping, grating, grinding symptoms, rgh disc or attachment perforation, anatomically degenerative changes of disc and hard tissues, perforation of posterior attachment.
- Hemarthrosis induced by trauma or surgery may cause fibrous adhesions that unite the condylar articular surface to the lower surface of articular disc. the elimination of the hinge movement in the disc condyle complex disrupts normal disc function during translatory movements.
- As the posterior border of the disc becomes thinned , it can displaced further into the discal space so that the condyle becomes positioned on the posterior border of the disc. This condition is called functional disc displacement. pt felt altered sensation but no pain. pain may occasionally experienced when pt bites. Function of the joint is some what compromised As the mouth opens and condyle moves forward ,a short distance of translatory movement can occur between condyle and disc until condyle once again assumes its normal position on the thinner area of disc (intermediate zone). Once it has translated over the posterior surface of the disc to the intermediate zone ,interarticular pressure maintains this relationship and the disc is again carried forward with the condyle through the remaining portion of the translatory movement.
- An opening click is felt as the condyle moves across the posterior border of the disc. Normal condyle disc function occurs during the remaining opening and closing movement until the closed joint position is approached. Then the second click is heard as the condyle once again moves from the intermediate zone to the posterior border of the disc. This stage of derangement is called the reciprocal click. The single click observed during opening movements represents very early stages of disc derangement disorder or what is also called internal derangement. The opening click can occur at any time during that movement depending on disc condyle morphologic characteristics, muscle pull, and the pull of the superior retrodiscal lamina. The closed click almost always occurs very near the closed or intercuspal position.
- The longer the disc is displaced anteriorly and medially ,the greater will be the thinning of the posterior border and more lateral discal ligament and inferior retrodiscal lamina will be elongated .Also protracted anterior displacement of the disc leads to a greater loss of elasticity in the superior retrodiscal lamina. If the posterior border of the disc becomes thinned , the disc can slip completely through the discal spaces, inter articular pressure collapse the discal space, trapping the disc in the forward position. The next full translation of the condyle is inhibited by anterior and medial position of the disc. The person feels the joint being locked in a limited closed position. Since the articular surfaces have actually been seperated , this condition is reffered to as a functional dislocation of disc .If the disc becomes functionally dislocated , the joint sounds are eliminated since no skidding can occur.
- Some persons with a functional dislocation of the disc are able to move the mandible in various lateral directions to accommodate the movement of the condyle over posterior border of the disc and the locked condition is resolved. If the lock occurs only ocassionally and the person can reslove it with no assistance , it is reffered to as a functional dislocation with reduction.
- This condition occurs when person is unable to return the dislocated disc to its normal position on the condyle. The mouth cannot be opened maximally because the position of the disc does not allow full translation of the condyle. Typically the initial opening will be only 25 to 30 mm interincisally , which represents maximum rotation of the joint.
- If the closed lock is continued, the condyle will be chronically positioned on the retrodiscal tissues. These tissues are not anatomically structured to accept force therefore there is likelihood that the tissues will breakdown. With this breakdown comes tissue inflammation.
- Mnadibular subluxation occurs when there is a momentory inability to close the mouth from a maximally open position. Self reducing Clinically observed TMJ movements during wide opening
- Hence, last portion of translation occurs with bodily shift of condyle & disc as a unit with a leap / thud of the complex
- Injection of sclerosing solutions like Sodium Psylliate, sodium morrhuate, sodium tetradecyl sulfate. Not very effective
- Reduction of dislocation by using digital pressure on lower posterior teeth in downward direction & anteriorly chin is elevated & pushed backwards after the condyles are distracted below the level of the articular eminence. Procedure performed with / without local / general anesthesia or sedation.
- The goal of disc repositioning procedure is to relocate the disc so that its posterior band can be returned to the normal condyle disc fossa relationship. Retropositioning can be achieved by one of three procedures.
- The disc is sutured to the condylar stump.
- Small perforations of 1to 3mm can be primarily closed.
- The goal of the procedure is to excise the pathologic posterior attachment and that portion of the displaced / atrophic disc that represent an obstruction or is presumed to be responsible for terminal jolting.