Dr.Saeid raoufi

1. (Diseases of the Temporomandibular joint in childeren)
Names: -Seyedsaeid Seyedraoufi
Oct 2022
Lecturer: Dr.Emir Bayandurov
Subject: Pediatric Oral Surgery
Pediatric Oral And Maxillofacial Surgery, January 16, 2018
by Marshall M. Freilich, DDS, MSc, FRCD(C)

2. Temporomandibular disorders
Keith classification
• Congenital and acquired growth disturbances
• Infections
• Ankylosis
• Traumatic lesions
• Dislocation (luxation)
• Internal derangement
• Degenerative diseases
• Tumors

3. Congenital growth disturbances
• Unilateral disorders
Hemifacial microsomia
Hemifacial microsomia is unilateral hypoplasia or aplasia of the
TMJ, it is an asymmetric, progressive deficiency which relates
to both soft tissues and the bony skeleton of the scull. The
developmental problem of the first and second branchial
arches can cause this disease.
It is classified in three groups
– Type I. :”minimanbible” All parts of the mandible are
present and the arch is normal, but they are small
– Type II.: Small and anomalously arched ramus, and
hypoplastic, anteriorly and medially situated condyle
– Type III.: total unilateral absence of the condyle and
ramus

4. Congenital grows disturbances
• Bilateral developmental anomalies of the first and
second branchial arch
– Treacher Collins syndrome (mandibulofacial
dysostosis)
It is characterized by a bilateral hypoplastic TMJ a
short ramus and a decreased face height. This
syndrome is a dominantly inherited abnormality. Its
rate of occurrence is 1:10000. Clinical appearance
is always bilateral. Retractions may be observes on
eyelids, the lower eyelashes may be missing. The
external ear is hypoplastic, hearing disturbance
exists.

5. Acquired TMJ deformities
Condylar hyperplasia
 It is the most frequent postnatal abnormality of
TMJ . It appears in the years before puberty.
 It is assumed that the cause of the changes lies
in the more active metabolism of the condyle
 Two different growth tendencies may be
distinguished
Vertical The mandible grows mainly in vertical
direction, which results vertically long ramus and
body.
Rotational Besides the enlarged condyle and
vertically long ramus, the convex enlargement of
the body leads to a crossbite and mouth opening
deviation. The enhanced metabolism may be
proved by bone scintigraphic examination.

6. Infections
• Before the advent of antibiotics, infectious diseases of the TMJ
were much common than today. Description from the 19th and
20th centuries revealed that infections of the ear and teeth often
spread to the joint. The primary causes of TMJ were infectious
diseases of childhood (scarlet fever, chickenpox, diphteria, etc.)
• Symptoms:
– Intense pain
– The most comfortable position for the patient is the opened
mouth
– Oedema, erythema above the joint, than fluctuation
– The cronic state was indicated by a fistula in the region of
TMJ.

7. • Trismus: This is an anomaly based on muscle spasm.
– Extracapsular process, the TMJ itself is not effected. Classic examples
of the lesion are the complications that arise in the course of
conduction anaesthetization. (infection, bleeding or nerve damage)
• Pseudo ankylosis:
– Intraarticular cause: fibrosus ankylosis.
– Extraarticular cause: Include the hyperplasia of the coronoid process
or its unification with the maxillary tuber or with the zygomatic
bone, or a fractured zygomatic arch. It may occur as a chronic scar
contracture of the temporal muscle as a consequence of irradiation or
surgery.
• Ankylosis: This is a bony unification of the condyle and the
glenoid fossa.
There is a lot of expression, which means the disability of the
movement of TMJ
trismus,
pseudo ankylosis,
ankylosis.

8. Ankylosis
• Etiology:
Trauma
 Rheumatoid arthritis
 Infection-This is now rare as a cause
 Tumors- Are similarly rarely observed in the TMJ
• In childhood there are a lot of vessels in the joint, which runs between the
condyle and the capsule. In the event of trauma hemarthrosis will develop,
which undergoes ossification.
• In adulthood 51% of the cases of polyarticular rheumatoid arthritis affect the
TMJ. ( usually only one) In childhood, the most serious consequence of
ankylosis caused by RA is the facial deformity due to the damage to the growth
center. The development of the lower third of the face is retarded and a „bird
face” results.

9. Diagnosis
 History
 Panoramic X-ray
 3D CT imaging

10. Treatment
• In childhood there are 4 groups in ankylosis and
the treatment varies group to group,
 On The X ray the articular gap is narrowed, but it can be
followed.
 The lateral parts of the articular surface there are much
more synostosis but on the medial deeper parts of the TMJ
the cartilaginous surfaces are preserved and the disk may be
distinguished
 There is a bridge-like synostosis between zygomatic arch
and ramus of the mandible. The medial part of the
capitulum is intact and able to function.
 The extent of synostosis is such that the TMJ can no longer
be recognized.

11. Treatment
• In adulthood
 To avoid re ossification some „interposed” is
recommended between the reformed articular
fossa and condyle. This may be the temporal
muscle, cartilage or alloplastic material.
 The first step in treatment is surgery. The
TMJ is usually exposed from preauricular
incision.
 In cases belonging to the first two groups the
TMJ can be easily recognized after exposure.
 After closure and postoperative period the
second step is functional treatment.

12. Injuries
 Dislocation-takes place most often in the anterior direction, the
condyle becomes positioned in front of the articular tubercule.
 Subluxation- The dislocation is not complete, the condyle can return
to the glenoid fossa
 Recurrent luxation - The luxation or subluxation occurs on a
number of occasions but there is no psychological factor inducting
compulsive movement.
 Habitual luxation is caused by compulsive movements.
• The terms luxation, distortion and dislocation are used when the
articular surfaces are totally separated from one another and the joint
is fixed in this extraarticular position. It may be induced by an
external ( hit, extraction) or an internal action (huge yawn, vomiting,
singing, dental procedure).
 The direct cause of spontaneous luxation is sudden disturbance of the
coordination of the muscles movement.

13. Symptoms
 The patient cannot close his or her
mouth
 The mandible is elastically fixated
 The articular fossa is empty
 Moderate pain in the joint

14. Treatment
• Acute: Reposition- The earlier the repositioning is attempted the
more easily succeeds. The thumbs are wrapped in gauze and
placed on the occlusal surface of the mandibular molars or
alveolar ridges. By pressing firmly on the molars and elevating
anteriorly with simultaneous backward pressure, the condyle is
relocated.
• Chronically persisting luxation: Reposition under general
anesthesia, when the reposition is unsuccessful, condylotomy may
be considered
• Recurrent: The reposition is generally easy but it is difficult to
avoid repetition of the luxation. Conservative or surgical
treatment.
• Habitual: It is difficult to know how to alter psychological
component that includes the compulsive movement.

15. Internal derangement
 The internal derangement means intracapsular damage of
the TMJ which primary arises from the incorrect
movement of the articular disk together with the
secondary changes of movement.
 The disease does not belong to developmental anomalies
or to other diseases of the TMJ
Symptoms
pain, deviation, repeated clicking when the mouth is
opened and reciprocal clicking when closed
Treatment is primary conservative and only rarely
surgical
Medication: NSAID, night bite guard (bite raising
appliances)

16.  A further change occur if the disc stretches and
becomes thinner and the articular gap is reduced
progressively in both posterior and anterior direction
 The following step is the rupture of the disc, so the
glenoid fossa and the condyle come into direct
contact
 The condyle slowly becomes pointed in the anterior
and posterior direction and finally degenerative
changes occur in the bone
 The healthy articular disc allows the appropriate
distance between the condyle and the glenoid fossa
Firstly the articular disc displaces, the posterior
fibers of the disc becomes loosened, the condyle
will be posteriorly positioned
Internal derangement

17. Degenerative diseases
 Osteoarthrosis (arthrosis deformans, osteoarthritis).
– It is a non-inflammatory degenerative diseases which mainly affects the articular
surfaces but it also induces reconstruction of and changes in the bone beneath
the articular surface.
– Symptoms: Pain, crepitation, restriction of articular movement
 Rheumatoid arthritis
– Autoimmune disease of the small periferial joints. In women it is three times
common than in men. In 10-15% of the cases involve a progressive variant with
articular destruction and deformities. The inflammation of the synovial
membrane is carasteristic. The inflammatoric process damages the joint and the
scar tissue impedes the movements.
– Symptoms: Intermittent pain, swelling and progressive restriction of the articular
movement. Typical that the small joints of the hand and foot become involve
first.

18. Degenerative diseases
Treatment
 Conservative
-pain killers
-normalisation of the occlusion
-interocclusal plates
-sedatives
-steroid intraarticulary
 Surgical
- condylectomy
- arthroplasty

19. • Gout
This is a metabolic disease, uric acid crystals are deposited in
and around the joints and these causes inflammatory
symptoms. Above the joint the skin is red and swollen and in
particular movement gives rise to pain.
• Other degenerative diseases
 Spondylitis accompanied by ankylosis:It differs from RA that here
primarily the ligaments around the joint undergo calcification and
ossification.
 Psoriatic arthritis: symmetric polyarthritis and negative rheumatoid
factors
 Post traumal arthritis: Arthritis may develop as a consequence of
trauma
 Condyle resorption: after bilateral condyle fracture or as a consequence
of otitis media

20. Tumors of TMJ
The tumors of TMJ are very rare. These could develop from
some parts of the joint or may spread from the environment of
the joint.
 Benign tumors The condyle may be enlarged for many
reasons, e.g.:
– acromegalia,
– fibrosus dysplasia,
– condylar hypertropia,
– osteoma, osteochondroma,
– chondroma stb.
 Common typical symptoms:
– Slow restriction of the movement of the joint
– Painless swelling in the region
 Metastases:
Primer tumor could be in
prostate, breast, kidney,
malignant melanoma, lung,
pancreas
etc.