The temporomandibular joint (TMJ) connects the mandible to the temporal bone. It contains the mandibular condyle, articular disc, fibrous capsule, and ligaments. Common TMJ disorders include dislocations, internal derangements of the disc, and arthritis. Surgical treatments for recurrent dislocations include eminectomy to remove the bony prominence or capsulorrhaphy to tighten the joint capsule. Internal derangements involve abnormal relationships between the disc and condyle.
Oral Hygiene Index (OHI) and Oral Hygiene Index-Simplified (OHI-S)SyedMajdi
This presentation is based on the Oral Hygiene Index (OHI) and Oral Hygiene Index-Simplified (OHI-S) that comes under the chapter of Dental Indices. The indices help us to determine a patient's level of oral hygiene by scoring debris and calculus accumulation in the mouth.
Gingival Index comes under the chapter of Dental Indices. Gingival Index is used to determine the severity of Gingivits/Gingival Inflammation in a patient.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. The Pathogenesis of infection in oro-facial region due to odontogenic origin is a common clinical issue. bacterial invasion to deeper tissues usually a spread from diseased dental pulp. Recent evidences indicated a multi-microbial nature. The spread of infection is governed by the thickness of the investing bone and the anatomical relation of the tooth root to the attached muscle. Infection could spread from one facial space to another, and the condition may be aggravated to life threatening situations.
The defense mechanism of gingiva includes GCF, Saliva, epithelial barrier and connective tissue cells. All these protect the periodontium from bacterial invasion.
As age affect the our body parts similary it also affect the periodontium. To treat people with different age efficiently we need to understand the changes associated with periodontim.
The periodontal examination should be systematic, starting in the molar region in either maxilla or mandible and proceeding around the arch. It is important to detect the earliest signs of gingival and periodontal disease.
CPITN INDEX (Community Periodontal Index of Treatment Needs)Jeban Sahu
Kalinga Institute of Dental Sciences, KIMS, BBSR-24
INTRODUCTION
CPITN was introduced by JUKKA AINAMO , DAVID BARMES , GORGE BEAGRIE , TERRY CUTRESS , JEAN MARTIN and JENNIFER SARDO-INFIRRI for Joint working committee of the WHO and FDI in 1982 .
Developed primarily to survey and evaluate periodontal treatment needs rather than determining past and present periodontal status i.e. recession of the gingival margin and alveolar bone .
SCOPE AND PURPOSE
PROCEDURE
SEXTANT
INDEX TEETH
INSTRUMENTS USED
CPITN PROBE
Introduced by WHO in 1978.
Weight: 5gms
Working force: 20-25 gms.
Designed for 2 purposes :
1. Measurement of pocket depth
2. Detection of Sub-gingival calculus
PROBING PROCEDURE
EXAMINATION PROCEDURE
CALCULATION OF CPITN
COMMUNITY PERIODONTAL INDEX (CPI)
This index is modification of CPITN.
SUMMARY
CPITN is a screening procedure for identifying actual and potential problems posed by periodontal diseases both in the community and in the individual, introduced in 1982.
The CPITN records the common treatable conditions namely,
- periodontal pockets
- gingival inflammation
- dental calculus
- other plaque retentive factors
CPITN PROBE (introduced by WHO in 1978) is used to measure of pocket depth & detect sub-gingival calculus.
COMMUNITY PERIODONTAL INDEX (CPI) is the modification of CPITN which includes measurement of “loss of attachment”
macroscopic/ clinical features of gingiva
With video clips
Short video descriptions
Lecture for 3rd BDS students
Periodontology
Periodontics aspect
Clinical features of the gingiva
the joint connecting an upper limb or forelimb to the body. It is a ball-and-socket joint in which the head of the humerus fits into the socket of the scapula.
Oral Hygiene Index (OHI) and Oral Hygiene Index-Simplified (OHI-S)SyedMajdi
This presentation is based on the Oral Hygiene Index (OHI) and Oral Hygiene Index-Simplified (OHI-S) that comes under the chapter of Dental Indices. The indices help us to determine a patient's level of oral hygiene by scoring debris and calculus accumulation in the mouth.
Gingival Index comes under the chapter of Dental Indices. Gingival Index is used to determine the severity of Gingivits/Gingival Inflammation in a patient.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. The Pathogenesis of infection in oro-facial region due to odontogenic origin is a common clinical issue. bacterial invasion to deeper tissues usually a spread from diseased dental pulp. Recent evidences indicated a multi-microbial nature. The spread of infection is governed by the thickness of the investing bone and the anatomical relation of the tooth root to the attached muscle. Infection could spread from one facial space to another, and the condition may be aggravated to life threatening situations.
The defense mechanism of gingiva includes GCF, Saliva, epithelial barrier and connective tissue cells. All these protect the periodontium from bacterial invasion.
As age affect the our body parts similary it also affect the periodontium. To treat people with different age efficiently we need to understand the changes associated with periodontim.
The periodontal examination should be systematic, starting in the molar region in either maxilla or mandible and proceeding around the arch. It is important to detect the earliest signs of gingival and periodontal disease.
CPITN INDEX (Community Periodontal Index of Treatment Needs)Jeban Sahu
Kalinga Institute of Dental Sciences, KIMS, BBSR-24
INTRODUCTION
CPITN was introduced by JUKKA AINAMO , DAVID BARMES , GORGE BEAGRIE , TERRY CUTRESS , JEAN MARTIN and JENNIFER SARDO-INFIRRI for Joint working committee of the WHO and FDI in 1982 .
Developed primarily to survey and evaluate periodontal treatment needs rather than determining past and present periodontal status i.e. recession of the gingival margin and alveolar bone .
SCOPE AND PURPOSE
PROCEDURE
SEXTANT
INDEX TEETH
INSTRUMENTS USED
CPITN PROBE
Introduced by WHO in 1978.
Weight: 5gms
Working force: 20-25 gms.
Designed for 2 purposes :
1. Measurement of pocket depth
2. Detection of Sub-gingival calculus
PROBING PROCEDURE
EXAMINATION PROCEDURE
CALCULATION OF CPITN
COMMUNITY PERIODONTAL INDEX (CPI)
This index is modification of CPITN.
SUMMARY
CPITN is a screening procedure for identifying actual and potential problems posed by periodontal diseases both in the community and in the individual, introduced in 1982.
The CPITN records the common treatable conditions namely,
- periodontal pockets
- gingival inflammation
- dental calculus
- other plaque retentive factors
CPITN PROBE (introduced by WHO in 1978) is used to measure of pocket depth & detect sub-gingival calculus.
COMMUNITY PERIODONTAL INDEX (CPI) is the modification of CPITN which includes measurement of “loss of attachment”
macroscopic/ clinical features of gingiva
With video clips
Short video descriptions
Lecture for 3rd BDS students
Periodontology
Periodontics aspect
Clinical features of the gingiva
the joint connecting an upper limb or forelimb to the body. It is a ball-and-socket joint in which the head of the humerus fits into the socket of the scapula.
SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptxOlaideOyetunde1
Spinal and epidural anaesthesia are forms of local regional anaesthesia. They are neuraxial anaesthesia which involves introduction of local anaesthetic agents into the subarachnoid space (Spinal) or epidural space (epidural). Indications includes surgeries below the umbilicus and and labour or postoperative analgesia. The most dangerous side effect is high spinal anaesthesia. Other common side effects are postspinal headaches, Hypotension, Bradycardia, infection,
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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2. OUTLINESS
Anatomy of the temporomandibular joint
Temporomandibular Joint Disorders Classification
Surgical Approaches to Mandibular Condyle and Its
Neck
2
3. Anatomy
►Also known as craniomandibular joint
►Articulate between squamous part of temporal bone
and head of mandibular condyle
►Diarthroidal or freely movable joint
3
4. CONT.
►TMJ articulation consists of :
Mandibular or Glenoid fossa
Articular eminance
Condyle
Separating disc
Joint fibrous capsule
Extra capsular check ligament
4
5. Mandibular fossa
►Limits: Ant.:- Articular eminance
Post.:- Postglenoid tubercle
►Articular area is formed by inferior aspect of
squamous part of temporal bone.
►Fossa is lined by a dense avascular fibro-cartilage
5
10. Separating disc
►The meniscus or articular disc or separating disc
divides articular space into 2 compartments
Lower/Inferior compartment:- between condyle and
disc(condylodiskal complex)
Upper/superior compartment:- between disc and
glenoid fossa(temporodiskal)
10
11. Cont.
►Disc blends medially and laterally with capsule
►Posteriorly disc is attached to glenoid fossa above and
to neck of condyle below. This area is called posterior
bilaminar zone or retro discoidal tissue which has a
rich neurovasular supply. Sensory branch of
auriculotemporal nerve is abundant here.
11
12. Cont.
►Vol. of upper joint space- 1.2 ml
Lower joint space- 0.9ml
►Disc has 3 zones
►Anterior band. - 2mm thick
►Posterior band- 3mm
►Intermediate zone - 1mm
12
18. Ligaments:
►Lateral or Temperomandibular ligament
TMJ Capsule is reinforced by this
Extends from articular eminance to condylar neck
Limits ANT. Excursion and prevents post. dislocation-
Hence called as check ligaments
►Accessory ligaments
Stylomandibular
sphenomandibular
18
20. Blood Supply
►Arterial supply:
Superficial temporal artery,
post. Auricular a.
branch of maxillary artery
Deep auricular a.
massetric a.
►Venous drainage:
venous plexus around capsule
20
40. A/c dislocation
►Causes of A/c dislocation
• Extrinsic or Latrogenic causes
• Intrinsic causes
1. Extrinsic causes
• Blow on chin while mouth is open
• Injudicious use of mouth gag during GA
• Excessive pressure on mandible during dental extraction
40
43. Cont.
►Clinical Features
• Unilateral or bilateral
• Unilateral:
► Difficulty in mastication and swallowing and speech with
profuse drooling of saliva
► Deviation chin towards contralateral side
► Lateral cross bite and open bite on contralateral side
► Mouth is partly open
► Affected condyle cannot be palpated
► Depression in front of tragus.
43
44. Cont.
►Bilateral
• Pain in temporal region
• Inability to close mouth
• Tenderness of masticator muscles
• Difficulty in speech, swallowing
• Excessive salivation
• Protruding chin
• Mandibular movements restricted
• Gagging of molar teeth
• Anterior openbite
• Hollowness in both preauricular regions
• Muscle spasm
44
46. Cont.
►Management
• Reduce tension, anxiety & muscle spasm by:
► reassuring the patient
► Tranqulizers and sedatives
► Pressure and massage to the area
► Manipulation by 3 ways
• Manipulation with out any form of anaesthesia
• " with LA
• " Under GA & sedation with muscle
relaxants.
46
47. Cont.
►Manipulation procedure
• Patient should be given assurance and asked to relax
completely
• LA is injected into glenoid fossa. This will eliminate pain
and spontaneous reduction
• Stand in front of patient and grasp mandible with both
hands. Thumbs are covered with guaze. As sudden
reduction can trap the thumbs. Thumbs are placed on
occlusal surface of lower molars and finger tips are
placed below chin. Exert downward pressure on
posterior teeth to depress jaw and at the same time
upward and backward pressure with fingertips
47
48. Cont.
Ask the patient to keep oral opening restricted.
Immobilization by barrel bandage for 10-14
days.
Semisolid diet
Avoid excessive oral opening, support chin
while yawning
NSAID -- for - 3- 5 days
48
49. Cont.
►Long standing dislocation. Dislocation for more than
one month
Reduction is done under GA
If manual reduction fails surgery
Open joint through preauricular incision, manipulation
by direct vision, if fails,
eminectiomy or condylectomy
49
50. Chronic recurrent or habitual
dislocation or subluxation
►It is the repeated episodes of dislocation where there is
abnormal anterior excursion of condyle beyond
articcular eminence, but patient is able to manipulate
back into normal position.
►Predisposing factors
Ligmentous and capsular flaccidity
Eminential erosion and flattening trauma
50
51. Cont.
►In these individuals yawning, vomiting, laughing may
precipitate subluxation.
►It is also seen in severe epilepsy, ehlers-danlos
sxndrome, teachers ,speakers, mucisians.
►C/C subluxation with pain:- in some patients, sudden
sharp and severe pain occurs when mouth is opened
widely.
51
52. Cont.
►Management:
Intermaxillary fixation or limiting oral opening by
elastics
Total immobilization of jaw for 3-4 weeks and
patient is kept on liquid diet
Use of sclerosing solution injection into joint
space:- Na tetradecyl sulphate - It brings about
fibrosis of capsule of but is short lived.
52
53. Cont.
Surgical Procedures:
► A. Capsule tightening procedures
Capsulorrhaphy:- shortening capsule by removing a
section and suturing to make it tight.
Placement of vertical incision in capsule and
drawing it tight by overlapping the edges and
suturing.
Reinforcement of joint capsule:- By turning down a
strip of temporal fascia and suturing to capsule
53
54. Cont.
► B. Creating a mechanical obstacle
Osteotomy on eminence and turn it down in
front of condylar head to prevent the
condylar movement forward.
Placement of a graft from zygoma over
eminence to increase size and Height.
Placement of implants (Vitallium mesh) to
Add height to eminence.
Osteotomy on zygomatic arch & depressing it
in front of condylar head to serve as obstacle to
forward movement.
L-shaped pins anchores in zygomatic process
of temporal bone & projecting it ant to condyle
54
55. Cont.
► C. Direct Restrain of Condyle
Temporalis fascia turned down and sutured to
lateral surface of articular capsule
Piece of fascia lata threaded through a hole in
zygomatic arch and second hole in condyle. Fascia is
tightened.
55
56. Cont.
►D. Removal of mechanical obstacle
Removal of torn meniscus or meniscectomy but it
causes pain, roughening condylar head,
occasional ankylosis.
High condylectomy:- Head of condyle shortened,
so less tendency to lock in front of articular
eminence.
Excision of condylar head above attachment of
lateral pterygoid muscle.
Eminectomy:- It allows condylar head to move
forward and backward free of obstacle, by the
excision of articular eminence.
56
57. Eminectomy
► Indications
• Recurrent dislocations
• C/c hyrermobility associated with severe pain
• Irreversible TMJ pain associated with clicking or
grating.
► Advantage
• Main joint cavity is not opened up and avoid injury
to meniscus and capsule
• Can be performed under LA.
57
58. Cont.
►Procedure:
• Small horizontal incision is made over zygomatic arch in
the region of articular eminence in front of tragus.
• Articular eminence is located 1.5cm ant. to external
auditory meatus.
• Distance is measures and location of eminence is
marked with ink prior to incision.
• Eminence is exposed by a T-incision. Horizontal over
the arch and vertical extending to apex of eminence.
58
59. Cont.
Periosteum is reflected until lateral part is exposed.
A series of bur holes are made at the base of eminence.
Extend the cut inward.
Eminence is cut and separated with osteotome
Smoothened with bone file
Irrigate and sutured
Pressure dressing for 48-72 HRS.
59
61. Internal derangement of TMJ
►Def:-it is the disruption of internal aspects of tmj,
in which an abnormal relationship exists b/w the
disc & condyle, fossa &articular eminance.
►Associated changes:-
• Synovitis
• Intracapsular adhesions & scarring
• Haemorrage
• Dystrophic calcifications
• Osteoarthritis
61
64. Anterior disc displacement with
reduction
►Disc is dislocated anterior to the condylar head.
►There is pain during translation
►Patient has a click on opening as the posterior part of
the disc interferes with condylar translation.
►A click less noticeable on closing as the condyle
returns to the original position.
64
68. Anterior disc displacement
without reduction
►The patient cannot open mouth fully.
►If patient attempts to open mouth there will be pain in
affected joint & deviation of mandible towards the
painful side,no click.
►It is a unilateral condition
68
70. R/F:
plain x-ray may be normal or there is signs of
osteoarthrosis
MRI…abnormal disc position
Management
reassurance, explanation
muscle relaxant and physiotherapy
Analgesics
manipulation under anesthetic
arthrocenesis
menisectomy and disc replacement 70
71. DEVELOPMENTAL DEFECTS
Condylar agenesis or aplasia
►Unilateral agenesis cause facial asymmetry &
deviation of mandible to the affected side during
opening.
►Treated by rib grafts.
71
72. Condylar hypoplasia
►May be congenital or acquired.
►Acquired may be due to:-
Birth injuries
Trauma
Radiation
Local extension of infection
72
73. Condylar hyperplasia
►It is usually unilateral.
►The chin is deviated away from the affected side.
►It is not usually associated with pain.
►Treated by surgical resection of condyle.
73
74. Fracture
►Fracture of neck of condyle usually follows trauma
to chin.
►It may be unilateral or bilateral.
►There will be pain & edema in the joint area.
►There is limitation of mouth opening or deviation
of mandible to the painful side during opening.
►Bilateral condylar fracture causes anterior open
bite.
74
75. DEGENERATIVE JOINT DISEASES (DJD)
(OSTEOARTHROSIS, OSTEOARTHRITIS
Definition:- variety of anatomic findings including
irregular ,perforated or severely damaged discs in
association with articular surface abnormalities i.e..
Flattening, erosion, lipping…….
75
76. Direct mechanical trauma: excessive mechanical
loading ----free radicals----intracellular damage.
Hypoxia perfusion theory: excessive intracapsular
hydrostatic pressure within the TMJ may exceed the
blood level---hypoxia
Neurogenic inflammation:- stretching of nerve-
rich retrodiscal tissue----cytokines
Osteoarthritis differ from osteoarthrosis in
2ry inflammation
76
77. C/F:
elderly most affected
pain
crepitus
tender joint
limitation of mouth opening
Course of the disease
Painful inflammatory, erosive phase, lasts for 3yrs.
Phase of resolution---- smooth out again
R/F
Bony changes: erosive, lipping, anvil shape deformity
,Ely’s cyst , irregularity in condylar head.
77
78. Effusion
Influx of fluid into the joint, usually either bleeding
following trauma or inflammatory exudates.
C/F:
pain & swelling over joint
limitation of movement
sensation of blocked ear
difficulty in occluding posterior teeth
R/F: widened joint space
Management:
Anti-inflammatory drugs
Rarely surgical drainage
78
82. Trismus
►It is the restriction of oral opening
►Causes:-
Infection:-
► Pericoronitis
► Ludwig`s angina
► Submasseteric abscess
► Infratemporal abscess
► Tb osteomyelitis
82
83. Cont.
• Trauma:-
►# of zygomatic arch
►# of mandible
• Inflammation:-
►Myositis
• Myositis ossificans
• Tetany:-due to hypocalcemia.
83
84. Cont.
• Mechanical blockade
► Elongation, exostosis, osteoma, osteochondroma of coronoid
process.
► Extra articular fibrosis
► Ossification of sphenomandibular ligament.
• Bleeding produced by needle puncture in medial
pterigoid muscle.
►
84
85. Surgical approach to the TMJ
85
1.Preauricular incision
2.Temporal extension
3.Question mark extension
4.Submandibular incision
5.Endaural approach
86. Pre auricular surgical approach to
TMJ
►Preparation of surgical site:-
Draping should expose entire ear & lateral canthus of
eye
Shaving of pre auricular area is done.
Cotton soaked in antibiotic ointment is placed into
external auditory canal.
►Marking of incision:- incision is outlined at the
junction of facial skin with helix of ear.
86
87. CONT.
►Infiltration of vaso constrictor:-vasoconstrictor is
injected subcutaneously in the area of incision to
decrease bleeding.
►Skin incision:-incision is made through the skin,
subcutaneous tissue to the superficial layer of
temporalis fascia
►Dissection of TMJ capsule:-
the flap is retracted anteriorly.
87
88. CONT.
► An oblique incision is made through the temporalis fascia from
the root of zygomatic arch to the upper corner of retracted flap.
expose the lateral aspect of zygomatic arch till the
articular eminence is exposed.
The tmj capsule is then seen
Inverted L-shaped incision is given in the capsule &
retract the flap.
cut along the lateral aspect of eminance & fossa
88
89. CONT.
A vertical incision is made in the capsule till the
condylar neck.
►Wound closure
Joint space is irrigated well
Haemorrhage is controlled
Wound is closed in layers
89
97. Clinical manifestations
►Early joint involvement:-
<15 years
severe facial deformity & loss of function
► Later joint involvement:-
after 15 years
less facial deformity & severe functional loss.
97
98. CONT.
►Unilateral ankylosis
• Seen in children or in person where the onset was in
childhood
• Obvious facial asymmetry.
• Deviation of mandible & chin to affected side
• Chin is receded with hypoplastic mandible on the
affected side.
• Roundness & fullness of face on affected side
• Flatness & elongation on unaffected side.
98
99. CONT.
Lower border of mandible on the affected
side has a concavity that causes a well defined
antegonial notch.
Some amount of oral opening may be
possible.
Cross bite may be seen.
Angles class 2 malocclusion on affected side
& unilateral crossbite
Condylar movements are absent on the
affected side.
99
101. Cont.
►Bilateral ankylosis
Mandible is symmetrical but micrognathic.
Bird face deformity with receding chin
Antegonial notch is well defined bilaterally
Angles class 2 malocclusion
Protrusive upper incisors
Anterior openbite
Oral opening less than 5 mm or many times there is nil oral
opening.
101
102. Cont.
Multiple carious teeth with poor periodontal health.
Crowding of teeth
Presence of impacted teeth
102
104. Diagnosis
►Orthopantomograph:- presence of
antegonial notch can be detected.
►Lateral oblique view:- gives anteroposterior
dimension of condylar mass and elongation of
coronoid process can be seen.
►Posteroanterior radiograph:- highlight
asymmetry in unilateral cases.
104
105. Radiographic findings
►Fibrous ankylosis :-
• reduced joint space
• hazy appearance
• normal anatomy can be appreciated
►Bony ankylosis:-
• complete obliteration of joint space.
• deformed condylar head
• elongation of coronoid process
105
106. Grading of ankylosis
►Type 1:-
condylar head is present without much
distortion.
fibrous adhesion make the movement
impossible
► Type 2:-
bony fusion of misshaped head & articular
surface.
no involvement of sigmoid notch & coronoid
process.
106
107. CONT.
►Type 3:-
• a bony block bridging across the ramus & zygomatic
arch
• medially an atrophic, dislocated fragment of former
head of condyle is found
• elongation of coronoid process is seen
►Type 4:-
• normal anatomy of TMJ is totally destroyed
• complete bony block b/w ramus & skull base.
107
108. Sequelae of untreated ankylosis
►Normal facial growth & development are
affected
►Speech impairment
►Nutritional impairment
►Respiratory distress in bilateral involvement
►Malocclusion
►Poor oral hygiene
►Multiple carious & impacted teeth.
108
109. Management
1. Condylectomy:-
• Indication:- fibrous ankylosis in which there is no
much deformity of condyle.
• Procedure:
► Preauricular incision
► Horizontal oseotomy cut at the level of condylar
neck
► Vital structures on medial aspect are protected by
the condyle retractor
► Condylar head is separated
► Rough bone is smoothed
► Wound is closed in layers.
109
110. CONT.
2. Gap arthroplasty:-
• Indication:- bony ankylosis, thick area of bone
obliterates entire joint, sigmoid notch & coronoid
process
• procedure:-
After the incision, 2 horizontal osteotomy cuts are made
Bone is removed until a thin medial bone is left.
Thin medial bone is removed with a chisel or osteotome.
A gap of at least 1 cm is created.
110
112. Cont.
3. Interpositional arthroplasty
Involves creation of a gap & insertion of a barrier b/w the cut
bony surfaces to minimize recurrence.
Inter positional materials used:-
a. Autogenous
Cartilagenous
► costochondral
► Metatarsal
► Sternoclavicular
112
113. Cont.
• Temporal muscle
• Temporal fascia
b. Heterogenous
• Chromatized submucosa of pig bladder.
• bovine cartilage
c. Alloplasts
• Metallic
► tantalum foil/plate
► stainless steel
► Titanium
► gold
113
116. Cont.
4. Interposition arthroplasty using autogenous
costochondral graft
• Costochondral graft is obtained by inframammary
incision
• 5th, 6th or 7th rib is taken.
• If 2 ribs are required intervening rib is left
• A min. Of 1.5 cm of costochondral junction should be
included
• It should be carved to simulate condylar head.
• The graft is fixed on the lateral aspect of ramus with
screws.
• A min. Gap of 0.5 to 1cm should be kept b/w graft &
glenoid fossa.
116
118. Cont.
5. Artificial replacement of joint
• Prefabricated condylar prosthesis made of steel or
vitallium can be used.
• Prosthesis may be commercially available or custom
fabricated
118
119. Complications during TMJ
ankylosis surgery
►During anesthesia:-
• Because of small mandible & difficulty in opening
mouth, intubation poses a problem.
• Aspiration of blood clot, tooth or foreign body as
throat cannot be packed prior to surgery
►During surgery:-
• Hemorrhage due to damage to superficial temporal
vessels, transverse facial artery, inferior alveolar
vessels, internal maxillary vessels, pterigoid plexus of
veins.
119
120. CONT.
Damage to external auditory meatus.
Damage to zygomatic & temporal branch of facial nerve
Damage to glenoid fossa
Damage to auriculo temporal nerve.
Damage to parotid gland
Damage to teeth
120
121. CONT.
►Post operative:-
• Infection
• Open bite
• Recurrence of ankylosis
• Frey`s syndrome
►frey`s syndrome
• First described by frey.
• Also known as auriculo temtoral nerve
syndrome
• Usually follows surgery of parotid gland &
TMJ, parotid abscess drainage
121
122. CONT.
►clinical features:-
Pain in auriculotemporal nerve distribution.
Associated gustatory sweating & erythema
Flushing on the affected side of face, associated
sweating in periauricular region & beneath the pinna.
122
126. Introduction
►MPDS is a pain disorder in which unilateral pain is
referred from trigger points in myofacial structures to
the muscles of head & neck
►Pain is constant, dull ache, it may range from mild to
intolerable.
126
127. Etiology
1. Psychogenic cause:-
• Psychologically unbalanced individuals, due to unusual
habits, there will be muscle disturbance, causing
occlusal disharmony leading to tmj disorder.
• Under emotional stress, skeletal musculature exhibits
hyperfunction, leading to muscle contraction & muscle
fatigue.
127
128. Cont.
2. Oral habits:-
Pipe smoking.
Sleeping on stomach with mandible supported by
forearm,
Teeth clenching,
Teeth grinding,
Lip licking,
128
130. Cont.
3. Occlusal disharmony:-
Inherent malocclusion; developmental deformity
Acquired malocclusion; failure to replace any lost
teeth for prolonged period causes drifting of teeth
causing occlusal imbalance.
Iatrogenic occlusal disharmony; faulty
restoration with high points, unbalanced vertical
dimension in dentures.
130
131. Pathophysiology
►Muscle injury causes increased tone of musculature
which leads to muscle fatigue & accumulation of
metabolic byproducts causing pain.
131
132. Signs & Symptoms
►Pain or discomfort anywhere in head & neck
region.
►Limitation of motion of jaw. normal vertical range
of motion is 40 to 50 mm. normal lateral range of
motion is 10mm. normal range of protrusive
movement is 10mm.
►Joint noises-clicking.
►Tenderness to palpation of the muscles of
mastication .
132
134. Treatment
►Elimination of the cause :-
• Occlusal discrepancies
• Stress:– counselling the patient
►Auriculotemporal nerve block:-
• A 26 or 27 gauge needle is inserted through the skin
just anterior to the junction of tragus & ear lobe.
• Needle is advanced to a depth of 1cm & 1.5 ml of
anesthetic solution is deposited.
• Pain is eliminated or decreased in 5 min.
134
135. Cont.
►Medications
NSAID - to reduce inflammation and to provide
pain relief, both in the muscles as well as in the
joints. For 14 to 21 days .
Aspirin 2 tabs 0.3 to 0.6 gm/ 4 hourly or
Piroxicam 10 to 20 mg / 3-4 times a day or
Ibuprofen 200 to 600mg / 3times a day
135
136. Cont.
Muscle relaxants - are recommended only for short
duration, as they produce sedation and addiction .
► Diazepam 2 to 5 mg bed time can be given 10 days.
Intramuscular local anesthetic injections in the
affected muscles can also give relief .
136
137. Cont.
►Physiotherapy -
Heat application:- increases local circulation
Moist or dry heating pads, hot moist application
of towels can be given for 15 to 20 min. 4 times a
day.
►Cryotherapy:-
Ice pack application to the painful area 4 times a
day for 20 min. it lowers pain by counter -
irritation
137
138. Cont.
Use of vapocoolant spray:- flouromethane
or ethyl chloride spray is applied for 5 sec.
Electrogalvanic stimulation:- stimulates
local circulation
Transcutaneous electronic nerve
stimulation:- increaese blood flow to the site
& interferes with pain sensation.
138
139. Cont.
• Active stretch exercises:- opening & closing
mouth for 10 times
►Stress management:-
• Acupuncture
• Yoga
• Hypnosis
• Meditation
• Deep breathing relaxation
139
141. Cont.
►Intra articular injections:-
2% lignocaine with hydrocortisone is injected once
in a month to relieve pain & inflammation.
The patient`s mouth is kept open wide with a
mouth prop.
1ml solution is injected with a 25 guage 1.5`` long
needle.
Needle is directed inward, forward & upward until it
strikes the roof of glenoid fossa at a depth of 2 to
3cm.
141
142. Cont.
• Needle is withdrawn 5mm & 1 ml solution is injected after
aspiration.
• After changing the direction downward rest of solution is
injected into lower joint space.
• Patient should be covered with antibiotics & anti-
inflammatory drugs.
►Occlusal splints:-
• 12 to 18 hrs use for 4 to 6 months.
• Fabricated in acrylic over maxillary teeth covering the
incisal & occlusal surfaces.
142
143. Cont.
A plat form is created perpendicular to lower incisors
,so the splint will disengage teeth & relax muscles.
It eliminates occlusal discrepancies.
►TMJ arthrocentesis:-
objectives:-
Improve disc mobility.
Eliminate joint inflammation
Eliminate pain.
143
144. Cont.
• technique:-
• Patient`s mouth is fully stretched open.
• 2 points are marked in the pre auricular
area indicating articular fossa & eminance.
• Auriculotemporal nerve block injection is given.
• 19 or 18 guage needle is inserted into the upper joint
space upto a depth of inch.
• Another 19 or 18 guage 15 inch needle is inserted at
the second mark corresponding to articular
eminance.
144
146. Cont.
10cc syringe is filled with ringer lactate solution &
connected to the first needle.
Solution pushed to distend the joint space.
Solution will come out through the second needle.
Upto 200 ml solution is pushed until clear fluid comes
out through the second needle.
1 ml hydrocortisone is injected before removing the
needle.
146
147. Cont.
• post arthrocentesis medication:-
• Naproxen sodium 275 mg 3 times daily
• Diazepam 2.5 to 5 mg at bed time for 2 weeks.
• Patient kept on soft diet.
• Procedure is repeated after 1 week at least for 3 or 4
weeks.
►Surgical treatment:-
• Condylar shave & arthroplasty:-remove several mm
of articular surface & recontouring.
147