4. • tm joint is most commonly affected by stress.
• of late huge population is affected by tmj problems.
• statistics reveals that 0.3-0.6% of the us population are affected by tmj disorders.
3/9/2018TMD/ G. GURU KARTHIK/92 4
5. INTRODUCTION
all the bones in the skull are attached with fibrous joint and are immovable expect for temporomandibular joint.
• the temporomandibular joint( tmj ) is a bilateral synovial articulation between the mandible and temporal bone. the name of the joint is
derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jawbone
or mandible.
• the most important functions of the temporomandibular joint (tmj) are mastication and speech.
3/9/2018TMD/ G. GURU KARTHIK/92 5
6. • TEMPOROMANDIBULAR JOINT IS ARTICULATION BETWEEN THE CONDYLAR HEAD OF MANDIBLE AND THE ANTERIOR PART OF THE
GLENOID FOSSA OF TWO TEMPORAL BONES.
• THE TMJ IS A GINGLYMOARTHRODIAL JOINT, A TERM THAT IS DERIVED FROM GINGLYMUS, MEANING A HINGE JOINT, ALLOWING MOTION
ONLY BACKWARD AND FORWARD IN ONE PLANE, AND ARTHRODIA, MEANING A JOINT OF WHICH PERMITS A GLIDING MOTION OF THE
SURFACES.
• THE COMMON FEATURES OF THE SYNOVIAL JOINTS EXHIBITED BY THIS JOINT INCLUDE A DISK, BONE, FIBROUS CAPSULE, FLUID, SYNOVIAL
MEMBRANE, AND LIGAMENTS. HOWEVER, THE FEATURES THAT DIFFERENTIATE AND MAKE THIS JOINT UNIQUE ARE ITS ARTICULAR
SURFACE COVERED BY FIBROCARTILAGE INSTEAD OF HYALINE CARTILAGE.
3/9/2018TMD/ G. GURU KARTHIK/92 6
7. PECULIARITIES OF TMJ
1. BILATERAL DIARTHROSIS – RIGHT & LEFT FUNCTION TOGETHER
2. ARTICULAR SURFACE COVERED BY FIBROCARTILAGE INSTEAD OF HYALINE CARTILAGE.
3. ONLY JOINT IN HUMAN BODY TO HAVE A RIGID ENDPOINT OF CLOSURE I.E. OCCLUSAL CONTACT THROUGH TEETH.
3/9/2018TMD/ G. GURU KARTHIK/92 7
17. MOVEMENTS
• rotational / hinge movement in first 20-25mm of mouth opening
• translational movement after that when the mouth is excessively opened.
3/9/2018TMD/ G. GURU KARTHIK/92 17
18. • translatory movement – in the superior part of the joint as the disc and the condyle traverse anteriorly along the inclines of the anterior
tubercle to provide an anterior and inferior movement of the mandible.
3/9/2018TMD/ G. GURU KARTHIK/92 18
19. 3/9/2018TMD/ G. GURU KARTHIK/92 19
Hinge movement – the inferior portion of the joint between
the head of the condyle and the lower surface of the disc to
permit opening of the mandible.
20. 1. depression of mandible
• lateral pterygoid
• digrastric
• geniohyoid
• mylohyoid
3/9/2018TMD/ G. GURU KARTHIK/92 20
21. 2. elevation of mandible
temporalis
masseter
medial
pterygoids
3/9/2018TMD/ G. GURU KARTHIK/92 21
22. 3. protrusion of mandible
• lateral pterygoids
• medial pterygoids
3/9/2018TMD/ G. GURU KARTHIK/92 22
23. 4. retraction of mandible
posterior fibres of temporalis,
deep part of masseter,
geniohyoid and digastric.
3/9/2018TMD/ G. GURU KARTHIK/92 23
24. GRINDING MOVEMENTS
the mandible rotates around a vertical axis through the contralateral mandibular head by a unilateral contraction of the lateral pterygoid muscle.
this is followed by a contraction of the posterior fibres of the temporal muscle, which repositions the head of the condyle.
when this occurs on alternate sides a typical grinding movement results.
if at the same time the other masticatory muscles contract, food can be crushed.
3/9/2018TMD/ G. GURU KARTHIK/92 24
25. AGE CHANGES OF THE TMJ
• condyle:
• becomes more flattened
• fibrous capsule becomes thicker.
• osteoporosis of underlying bone.
• thinning or absence of cartilaginous zone.
• disk:
• becomes thinner.
• shows hyalinization and chondroid changes.
• synovial fold:
• become fibrotic with thick basement membrane.
• blood vessels and nerves:
• walls of blood vessels thickened.
• nerves decrease in number
3/9/2018TMD/ G. GURU KARTHIK/92 25
26. THESE AGE CHANGES LEAD TO:
decrease in the synovial fluid formation
impairment of motion due to decrease in the disc and capsule extensibility
decrease the resilience during mastication due to chondroid changes into collagenous elements
dysfunction in older people
3/9/2018TMD/ G. GURU KARTHIK/92 26
29. • HEMI FACIAL MACROSOMIA IS THE SECOND MOST COMMON CRANIOFACIAL ANAMOLY CLEFT LIP & PALATE
• FREQUENCY: 1 IN 5600 LIVE BIRTHS
• M:F = 3:2
• RIGHT: LEFT = 3:2
3/9/2018TMD/ G. GURU KARTHIK/92 29
30. • DIFFERENT TYPES OF HFM
• TYPE-I
• TYPE-II A
• TYPE –IIB
• TYPE-III
3/9/2018TMD/ G. GURU KARTHIK/92 30
31. TREATMENT OF STRUCTURAL MALFORMATIONS
• PHASE-I: EARLY INTERVENTIONS FOR JAW ASYMMETRIES
INITIAL PHASE
FUNCTIONAL APPLIENCES IN CASES OF TYPE-I & IIA
GENERALLY STARTED AT THE AGE OF 6YRS I.E., ERUPTION OF 1ST MOLARS
• PHASE-II: MANDIBULAR SURGERY
SECOND PHASE OF TREATMENT
SURGICAL LENGTHENING OF MANDIBLE
3/9/2018TMD/ G. GURU KARTHIK/92 31
Costochondral graft
Distraction osteogenesis
32. • PHASE – III : CLOSURE OF OPEN BITE – AFTER SURGICAL CORRECTION OF THE AFFECTED RAMUS
• PHASE -IV: ORTHODONTIC TREATMENT
• ADDITIONAL SURGICAL PROCEDURE: RECONSTRUCTION OF EAR, CHIN ASYMMETRY BY GENIOPLASTY, DNS, SOFT TISSUE
AUGUMENTATION
3/9/2018TMD/ G. GURU KARTHIK/92 32
33. MANDIBULOFACIAL DYSOSTOSIS:
• TREACHER COLLINS SYNDROME:
• HYPOPLASIA AND DISCONTINUITY OF ZYGOMATIC ARCH, DOWNSLANTED PALPEBRAL FISSURES, MISSING EYELASHES ON LOWER LID,
MALFORMED AND VARYING DEGREE OF HEARING LOSS, POSTERIOR MAXILLA SHORTENED.
MANDIBLE:
SHORT CONDYLE
VARYING CORONOID SIZES
MANDIBULAR PLANE ANGLE IS STEEP
RAMUS HEIGHT IS SHORT
3/9/2018TMD/ G. GURU KARTHIK/92 33
34. TREATMENT
• MIDDLE EAR RECONSTRUCTIONS
• DNS
• RHINOPLASTY
• MANDIBULAR RAMUS LENGTHENING WITH/WITHOUT JOINT SURGERY
• ORTHODONTICS
NAGERS SYNDROME TREATMENT IS SAME AS MFD AS SAME ORGANS ARE AFFECTED.
3/9/2018TMD/ G. GURU KARTHIK/92 34
35. OVERGROTH DISORDERS:
• UNILATERAL CONDYLAR HYPERPLASIA
• DEVELOPMENTAL CONDYLAR HYPERPLASIA
TREATMENT:
• SURGICAL CORRECTION OF MANDIBULAR LENGTH AUGMENTED WITH LEFORTE- 1 OSTEOTOMY.
3/9/2018TMD/ G. GURU KARTHIK/92 35
40. • ONE OF THE MOST COMMON TMD’S
• SYMPTOMS ARISE FROM SYNOVIUM, CARTILAGE, OR SURROUNDING STRUCTURES SUCH AS THE CAPSULE, BURSA AND TENDONS.
• ANKYLOSING SPONDYLITIS PATIENTS SUFFER FROM TMJ INVOLVEMENT MORE OFTEN THAN PATIENT WITH PSORIATIC ARTHRITIS
• CORTICAL RESORPTION OF CONDYLE IS MORE COMMONLY SEEN IN FEMALES THAN IN MALES IN RA.
• IN AS CORTICAL RESORPTION IS MORE COMMON IN MALES
•
3/9/2018TMD/ G. GURU KARTHIK/92 40
41. HOW DOES IT OCCUR?
TMJ IN ACTION.
EXCESSIVE LOADING OF TMJ.
CHONDROCYTES DEFECTIVE REMODELING IN CARTILAGE.
SCLEROTIC BONE REMODELING.
EXCESSIVE AND REPETITIVE STRESS ON TMJ
RELEASE OF WATER AND PROTEASES FROM JOINT.
DEGENERATION OF CARTILAGE.
3/9/2018TMD/ G. GURU KARTHIK/92 41
42. CLINICAL FEATURES
• IT IS DIVIDED INTO PRIMARY AND SECONDARY FORMS
• PRIMARY- 5TH OR 6TH DECADE OF LIFE.- NO PREDISPOSING FACTORS.
• SECONDARY-ANY TIME IT CAN HAPPEN.- INFLAMMATION/TRAUMA/SEPSIS/ASEPTIC NECROSIS/DM.
• REFERRED PAIN RADIATING TO THE HEAD AND NECK ARE COMMON FINDINGS.
• USUALLY ONE TMJ IS INVOLVED AND BILATERAL INVOLVEMENT IS NOT UNCOMMON.
• RADIOGRAPHIC EVIDENCES ARE SEEN IN 44% OF ASYMPTOMATIC CASES.
3/9/2018TMD/ G. GURU KARTHIK/92 42
43. • PTS RARELY COMPLAIN OF MORNING STIFFNESS.
• OSTEOPHYTES ARE FORMED DUE TO FRICTION.
• TENDERNESS STARTS INCREASING AS THE LOADING OF TMJ INCREASES AS THE DAY PROGRESSES.
• IF SYMPTOMS ARE PRESENT USUALLY LASTS FOR 30 MIN.
• PALPABLE MASSES CAN BE FELT IN THE PREAURICULAR REGION.
• IMAGING LIKE MRI/T WILL REVEAL ABOUT:
1. DISK PERFORATIOS
2. CONDYLAR HEAD SHAPE
3. OSTEOPHYTES
4. CYST FORMATION
5. JOINT NARROWING
6. SURFACE EROSIONS
3/9/2018TMD/ G. GURU KARTHIK/92 43
44. HOW TO CONFIRM?
• SYNOVIAL FLUID ANALYSIS:
1. ELEVATED INFLAMMATORY MEDIATORS.
2. WHITE CELL COUNT.
3/9/2018TMD/ G. GURU KARTHIK/92 44
52. • RAMFJORD 1N 1960 WAS CREDITED WITH RELATING SPLINT THERAPY TO MUSCULAR FUNCTION
• IN 1970-1980’S ANTERIOR REPOSITIONING SPLINTS WERE INTRODUCED AND BEING USED TILL NOW FOR THE CORRECTION OF INTERNAL
DERANGEMENT
3/9/2018TMD/ G. GURU KARTHIK/92 52
53. SPLINT THERAP IN MYOFASCIAL PAIN
• RATIONALE FOR USE OF SPLINT THERAPY:
1. ALLOWS FREE MANDIBULAR MOVEMENTS.
2. DECREASES MUSCULAR ACTIVITY EVIDENCED IN EMG STUDIES.
3. DOES NOT ALLOW FULL FLEXION OF CLOSING MUSCLES.
4. PROVIDES STABLE DENTAL OCCLUSION.
5. AIDS IN COGNITIVE AWARENESS.
6. POSSIBLE EFFECT IN BRUXISM.
7. PLACEBO EFFECT.
3/9/2018TMD/ G. GURU KARTHIK/92 53
Symptoms reduced in 70-90% of cases
54. TYPES OF SPLINTS USED
• STABILIZATION SPLINT- MOST COMMONLY USED IN MPDS.
• REPOSITIONING SPLINT
• PIVOT SPLINT
• SOFT SPLINT
• BITE PLANE SPLINT
• MANDIBULAR ORTHOPEDIC REPOSITIONING SPLINT
3/9/2018TMD/ G. GURU KARTHIK/92 54
55. • SPLINT THERAPY USUALLY RESPONDS POSITIVELY IN 70-90% OF CASES.
• THE MATERIAL WITH WHICH THE SPLINT IS MADE, OCCLUSAL SCHEME INCORPORATED, TIME IN WHICH PT IS WORN HAVE MINIMAL
SIGNIFICANCE INN OVERALL EFFICACY OF TREATMENT.
3/9/2018TMD/ G. GURU KARTHIK/92 55
56. SPLINTS IN INTRACAPSULAR TMD’S
• VERY EFFECTIVE IN MANAGEMENT OF PAIN IN INTRACAPSULAR TMJ DISORDERS.
• MAINLY USED IN ANTERIORLY DISPLACED DISKS WITH OR WITHOUT REDUCTION.
• PIVOT SPLINTS ARE USED.
3/9/2018TMD/ G. GURU KARTHIK/92 56
57. MECHANISM:
CONDYLAR HEAD BEING HELD IN MORE INFERIOR POSITION, ANT. POSITION WILL MECHANICALLY PERSUADE
THE DISK TO MORE FAVORABLE POSITION
UNLOADING OF JOINT
DECREASED INFLAMMATION
INCREASED RANGE OF MOTION
DECREASED SIGNS AND SYMPTOMS OF TMJ DISORDER.
3/9/2018TMD/ G. GURU KARTHIK/92 57
58. DISK DISPLACEMENT WITHOUT REDUCTION :
PAIN IN TMJ REGION DUE TO IMPINGEMENT OF RETRODISCAL TISSUE
SOME PTS VERY SUCCESSFUL IN ADAPTING TO NEW ENVIRIONMENT BY RETRO DISCAL TISSUE BECOME MODERATELY FIBROSED SUCH AS TO ACT
AS PSEUDO DISK.
SPLITS HELPS THE PT DECREASING PAIN DURING THE EARLY TRANSCITION OF RETRODISCAL TISSUE GETTING FIBROSED
FLAT TYPE OF SPLINT SHOULD BE USED
3/9/2018TMD/ G. GURU KARTHIK/92 58
59. IN ARTHRITIS:
• REDUCING SYMPTOMS IS THE MAIN GOAL
• IT CAN BE CONSIDERED AS ONLY A PART OF THERAPY RATHER THAN ADJUVANT ( THERAPY INCLUDES DRUGS, PHYSICAL, SURGICAL).
• MAIN AIM IS TO REDUCE THE JOINT LOADING AND PROVIDING STABLE OCCLUSION.
BOERING AND ASSOCIATES CONCLUDED SAYING THAT USAGE OF SPLINTS DOESN’T DECREASE THE PROGRESSION OF DISEASES.
3/9/2018TMD/ G. GURU KARTHIK/92 59
60. SPLINT THERAPY IN SURGERY OF TMJ:
• FOR INTRACAPSULAR DISK DISPLACEMENT AS A PART OF PRELIMINARY CONSERVATIVE THERAPY SPLINTS ARE PRESCRIBED.
• IT CAN BE USED IN VARIOUS SURGICAL MODALITIES LIKE
ARTHROSCOPY
ARTHROCENTESIS
ARTHROTOMY
CONYLECTOMY
TMJ REPLACEMENT
ORTHOGNATHIC SURGERY.
3/9/2018TMD/ G. GURU KARTHIK/92 60
61. • KIRK SAID THAT DISK REPOSITIONING IS A CLINICAL TERM RATHER THAN AN ANATOMICAL RECAPTURE OF JOINT HAVING CONCLUDED
AFTER STUDYING 30 PT’S.
3/9/2018TMD/ G. GURU KARTHIK/92 61
64. INFLAMMATION:
• TREATMENT MODALITIES:
1. THERMAL THERAPY. – REDUCES THE NERVE CONDUCTION, INCREASES PAIN THRESHOLD, VASODIILATION
2. ULTRASOUND- ANTI INFLAMMATORY EFFECT, INCREASES CELL, VASCULAR PERMEABILITY- PULSED US AT 3MHZ, 0.5-0.8 W/CM2, FOR 5-
8 MIN, ACTS AT -2 CMS FROM SKIN SURFACE.
3. COLD- TO CONTROL INFLAMMATION BY VASOCONSTRICTION, PREVENTING RELEASE OF HISTAMINE.
4. IONTOPHOROSIS. - COMMON DRUGS USED ARE METHYL PREDISONE, DEXAMETHASONE, NOT THAT EFFECTIVE.
5. TENS.- BASED ON GATE CONTROL THEORY, OPTIMAL STIMULATION PARAMETERS ARE 1 HZ, PULSE WIDTH OF 75-100 MICRO SEC.
3/9/2018TMD/ G. GURU KARTHIK/92 64
65. HYPERMOBILITY:
• MOVEMENT OF CONDYLE BEYOND THE ARTICULAR CREST IS DEFINED AS HYPERMOBILITY.
• COMMONLY COMPLAINS OF JAW GOING OUT OF PLACE.
TREATMENT:
• DO NOT OPEN YOUR MOUTH WIDE.
• ADVICE THE PATIENT WHILE YAWNING TO PRESS TONUE AGAINST THE PALATE WHICH REDUCES THE OPENING OF MOUTH TO 25CM.
3/9/2018TMD/ G. GURU KARTHIK/92 65
66. HYPOMOBILITY:
• ANKYLOSIS
• SEVERE DEGENARATIVE DISORDERS
• FRACTURES
• NEOPLASIA
• APLASIA
• DYSPLASIA OF TMJ
3/9/2018TMD/ G. GURU KARTHIK/92 66
67. DIAGNOSIS:
• MANDIBULAR DEPRESSION : UNABLE TO OPEN MOUTH 36MM OF INTERINCISAL OPENING.
• MANDIBULAR PROTRUSION: ACTIVELY PT UNABLE TO ACHIEVE END—END POSITION OF CENTRAL INCISORS
• FUNCTIONAL PROTRUSION: LOWER CENTRAL INCISORS MOVE PAST THE UPPER CENTRAL INCISORS
• MANDIBULAR LATERAL EXCURSIONS: UNABLE TO ACHIEVE END-END POSITION OF RIGHT BOTTOM CANINE TO THE RIGHT UPPER CANINE,
THIS APPLIES CONTRA LATERALLY ALSO.
3/9/2018TMD/ G. GURU KARTHIK/92 67
68. TREATMENT FOR PERIARTICULAR TISSUE TIGHTNESS AND DISK DISPLACEMENT:
• FINGER SPREAD STRETCH.
• DISTRACTION.
• LATERAL GLIDE.
• TRANSLATION.
• STATIC TONGUE BLADE TECHNIQUE.
• CONTINUOUS PASSIVE MOTION.
• IMF.
• ISOMETRIC CONTRACTION EXERCISES.
3/9/2018TMD/ G. GURU KARTHIK/92 68
69. • TONGUE UP AND OPEN/CLOSE
• FINGER SPREAD STRETCH AND STATIC TONGUE BLADE STRETCH
• DENTAL ROLL DISTRACTION.
• HORIZONTAL TONGUE BLADE EXERCISE.
3/9/2018TMD/ G. GURU KARTHIK/92 69
71. • INCREASED HORIZONTAL OVERLAP CAUSES DISK DISPLACEMENT.
• BALANCED OCCLUSION AND GROUP OCCLUSION REDUCES THE TMJ DISORDERS.
• MISSING POSTERIORS DOESN’T INCREASE THE RISK OF TMJ DISORDERS.
• INTRAARTICULAR TMJ DISORDERS DEMONSTRATES AN INCREASE IN CLASS II MOLAR RELATIONSHIP ON LEFT SIDE.
• ORTHODONTIC TREATMENT NEITHER INCREASES NOR DECREASES THE TMJ DYSFUNCTION.
• POSITION OF CONDYLE IN SYMPTOMATIC PATIENTS MAY BE A MATER OF CHANCE RATHER THAN A DEPENDABLE PREDICTOR.
• ORTHOGNATHIC SURGERY LIKE BSSO HAS HIGH IMPACT ON TMJ DISORDERS.
3/9/2018TMD/ G. GURU KARTHIK/92 71
77. • ANNONDALE WAS THE FIRST PERSON TO DESCRIBE SURGERY FOR TMJ INTERNAL DERANGEMENT IN 1887.
• AZTECS USED THORNS TO PERFORM ARTHROCENTESIS AS LONG AS 500 YRS AGO.
3/9/2018TMD/ G. GURU KARTHIK/92 77
78. • ARTHROCENTESIS.
• ATHROTOMY WITH DISK REPAIR
a. PLICATION
b. BILAMINAR FLAP REPAIR
c. ARTHOSCOPY WITH DISCECTOMY
d. ARTHOSCOPY WITH DISCECTOMY WITH AUTOLOGOUS GRAFT/ FLAP RECONSTRUCTION/ALLOPLASTIC DISK REPLACEMENT
e. CONDYLECTOMY.
3/9/2018TMD/ G. GURU KARTHIK/92 78
79. ARTHROCENESIS
3/9/2018TMD/ G. GURU KARTHIK/92 79
LC = lateral canthus; T = tragus; A = 10mm
from the middle of the tragus and 2mm below
the canthotragal line. B = 10mm further
along the canthotragal line and 10mm below
it; C= 7mm anterior from the middle of the
tragus and 2mm inferior along the
canthotragal line; and D= 2–3mm in front of
point A.
85. 3/9/2018TMD/ G. GURU KARTHIK/92 85
• 1933 Risdon used gold foil for gap arthroplasty
• Eggers and mercurri in 1946 & 47 used tantalum
foil for gap artheoplasty.
• Total joint replacement was first come into
exsistance in 1970,s by kent-vitek prosthesis
86. SUBLUXATION
It is a triad of Ligamentous & capsular laxity
Eminential erosion & flattening
Trauma.
MANAGEMENT
•IMF With elastics
•Sclerosing agents
Sodium psylliate
Sodium morrhuate
Sodium tetradecyl sulfate
•Capsulorrhapy
3/9/2018TMD/ G. GURU KARTHIK/92 86
87. DISLOCATION OF TM JOINT
ACUTE, CHRONIC RECURRENT, LONG STANDING--Uni/Bi
Dislocation is a displacement of the condylar head completely
out of glenoid fossa, which usually can not be reduced
by the patient.
Subluxation is a displacement of condylar head, which patient
can reduce himself
CAUSES:
Extrinsic forces
Trauma
GA
Extraction
Intrinsic forces
Excessive yawning, Vomiting, Blowing,
Hysterical fits
dr.godhi TMJ
3/9/2018TMD/ G. GURU KARTHIK/92 87
88. MANAGEMENT
•Reassuring patient
•Tranquilizers/sedatives
•Pressure &massage to the area
•Manipulation
-Manual reduction
-Indirect reduction
•Direct reduction
- Condylotomy,condylectomy
- Eminectomy
- Augmentation of eminence
- Dautery’s procedure
- Osteotomy
- Chemical capsulorrhaphy
dr.godhi TMJ
3/9/2018TMD/ G. GURU KARTHIK/92 88
90. REFERENCES:
• FONSECA – ORAL AND MAXILLOFACIAL SURGERY – TMD 4TH VOLUME.
• DAVID A. KEITH-SURGERY OF TEMPOROMANDIBULAR JOINT.
• A NEW SURGICAL CLASSIFICATION FOR TEMPOROMANDIBULAR JOINT DISORDERS. IJOMS 2013;42 VOLUME 218-222.
• DOES INJECTION OF PLASMA RICH IN GROWTH FACTORS AFTER TEMPOROMANDIBULAR JOINT ARTHROSCOPY IMPROVE OUTCOMES IN
PATIENTS WITH WILKES STAGE IV INTERNAL DERANGEMENT? A RANDOMIZED PROSPECTIVE CLINICAL STUDY IJOMS 2016
3/9/2018TMD/ G. GURU KARTHIK/92 90
