Trismus

Trismus may be defined as inability to open the mouth due to muscle spasm, but the term is usually
used for limited movement of the jaw from any cause and usually refers to temporary limitation of
movement.

Causes of temporary limitation of mandibular movement:

1. Intracapsular causes:
Infective arthritis
Juvenile arthritis
Traumatic arthritis and disc damage
Intracapsular condylar fracture
2. Pericapsular causes:
Irradiation and other causes of fibrosis
Dislocation
Condylar neck fracture
Infection and inflammation in adjacent tissue
3. Muscular causes:
Pain dysfunction syndrome
Myalgia caused by bruxism
Haematoma from inferior dental nerve block
Tetanus
4. Other causes:
Oral sub mucous fibrosis
Systemic sclerosis (scleroderma)
Zygomatic and maxillary fractures
Some drugs: phenothyasin, metoclopramide
Craniofacial anomalies involving the joint

Causes of Trismus:

1. Infection and inflammation in or near the joint:

Acute pericoronitis
Mumps (Acute myxovirus disease involving parotid gland)
Suppurative parotitis
Suppurative arthritis
Osteomyelitis (inflammation of bone)
Cellulites (inflammation of loose connective tissue)
Ludwig’s angina
Submesseteric abscess
Infra-temporal abscess
Mandibular block infection
Infection in the pterygoid, lateral pharyngeal or submandibular spaces
2. Injuries:
Unilateral condylar fracture
Bilateral condylar fracture
3. Tetanus and Tetany
4. temporomandibular pain dysfunction syndrome
5. Histerical Trismus
6. Some drugs: phenothyasin, metoclopramide
Management:

In all these conditions the essential measure is to relieve the underlying causes.
Medicinal: Muscle relaxant
Mechanical exercise:
o Wooden spatulae
o Acrylic screw
Use of brisement force

Ankylosis

Inability to open the mouth beyond 5mm of interincisal opening due to fusion of the head of the
condyle of the mandible with the articulating surface of the glenoid fossa and termed as ankylosis of the
Temporomandibular joint. It may be partial or complete or either fibrous or bony.

Classification:

1. Partial or complete ankylosis

2. Fibrous or bony ankylosis
3. False ankylosis or true ankylosis
4. Extra-articular or intra articular ankylosis
5. Unilateral or bilateral ankylosis

Causes of Ankylosis:

1. Causes of mechanical interfere with opening (pseudo-ankylosis):

Trauma: due to fracture of Zygomatic bone or arch
Hyperplasia: developmental over growth of the coronoid process
Neoplasia:
Osteoma
Osteochondroma
Osteosarcoma
Miscellaneous: congenital anomalies
2. Causes of extra caplsular ankylosis (false-ankylosis):
Trauma: wounds or burns which causes periarticular fibrosis
Infection: chronic periarticular suppuration
Neoplasia:
Chondroma
Chondrosarcoma
Fibrosarcoma of the capsule
Particular fibrosis due to:
Irradiation
Oral submucous fibrosis
Progressive systemic sclerosis
3. Causes of intra caplsular ankylosis (true-ankylosis):
Trauma:
Intra-capsular comminuted fracture of condyle
Penetrating wounds
Forcep delivery at birth

Infection:
Otitis media
Osteomyelitis of jaw
Pyogenic arthritis
 Systemic juvenile arthritis:
Psoriatic arthropathy
Osteo arthritis
Rheumatoid arthritis
Neoplasia:
Osteoma
Chondroma
Osteochondroma
Miscellaneous:
Synovial chondromatosis

Clinical features:

It occurs in any age but commonly occurs below 10 years.

Both sexes are equally affected.
Inability to open the jaw.
Difficulty in mastication the food.
Compromised oral hygiene and speech.
Disturbance in respiration leading to breathing distress.
Patient has multiple carious teeth in the mouth and seeks consultation for tooth-ache.
A scar on the chin can be seen with history of trauma.
In the unilateral ankylosis, some degree of movement is possible because of the normal joint on the
opposite side. In this case, face is asymmetrical with fullness on the affected side of the mandible
and flattening on the unaffected side.
In bilateral ankylosis, it develops a typical ‘bird face’ appearance with a retruded chin.
In fibrous ankylosis, some degree is also possible.
In bony ankylosis, interincisal opening is invariably less than 5mm.

Radiological examination:

X-rays for TMJ both in open and closed mouth position should be taken.
In fibrous ankylosis, the joint space is visible but no movement of the condyle is seen.
In bony ankylosis, a bony mass is seen in the area of the joint with obliteration of the joint space
along with restricted movement of the condyle.
Cephalometric radiograph is helpful in assessment of the mandibular and maxillary skeletal defects.
Management:

1. Condylectomy
2. Gap arthroplasty
3. Inter positional arthroplasty:
Autogenous:
o Temporal muscle
o Temporal fascia
o Dermis
o Cartilaginous grafts-
Costochondral
Sternoclavicular
Auricular cartilage
Alloplastic materials:
o Stainless steel
o Silastic
o Titanium
o Tantalum foil/plate
 o Teflon (polytetrafluoethlene)

Myofacial pain dysfunction syndrome

Causes:

Causes are usually unknown, but some factors are identified:

o Oral habits: Para functional activity such as clenching or grinding of the teeth, finger nail, pencil or
cheek chewing
o Stress, psychological disturbance or psychological factor or psychiatric illness
o Occlusal disturbance or disharmony
o Decreased vertical height
o Trauma or physical injury
o Bruxism
o True joint diseases

Clinical features:

1. It is predominantly a young patient’s condition (20-40yrs) and affects women more commonly than
man.
Female: male = 4: 1
2. Pain mainly muscle associated pain
3. Pain is dull and worse by mastication
4. Pain felt in front of the ear
5. Limited mouth opening
6. Translatory movement of joint may be normal
7. Joint sound- crepitus or clicking
8. Re-current headache
9. Gar symptoms

Treatment:

Conservative treatment:
1. First line: Keeping the muscles warm, minimizing chewing, analgesics (NSAIDs) as well as
asking the patient to watch for and control daytime Para functional activity.
2. Second line:
a) Soft vinyl mouth guard (for night use only, for about 6 weeks).
b) The occlusally balanced or stabilization appliance is a rigid acrylic device made to fit closely
into the occlusal surfaces of upper and lower tooth.
c) Physiotherapy of various forms has been shown to be effective in reducing pain and
increasing mobility.
d) Antidepressant medications such as amitryptiline, dothiene, fluxetine or paroxetine have been
used with considerable success for some patients.
e) It is certainly worth while treating any obvious local cause such as pericoronal infection or a
high restoration.
f) Help should be sought from a psychologist or psychiatrist.

Surgical treatment:
Arthrocentesis
Menisectomy
Disc repositioning operation
Condylotomy
Condylectomy
Dislocation of TMJ

Dislocation of a joint is a displacement of one component of the joint beyond its normal limits,
without spontaneous return to its normal position.
The condyle moves to articular eminence that marks the anterior limit of the condylar excursion. Once the
condyle slips over the articular eminence to come and lie anterior to the eminence in the infratemporal
space, it is known to be dislocated. The capsule of the joint along with temporomandibular ligament is either
sufficiently relaxed or torn to let this all happen.
If both joint are dislocated and the patient is dentate the mouth remains wide open, although
sometimes the patient may be able to close toward a protruded position.
If only one joint is dislocated then there is a marked deviation to the opposite and the teeth may be
brought closer together but still nowhere near back into occlusion. For a few hours after the event there
remains a depression just in front of the ear where the condyle would normally be found, but in times that
fills with oedema.
Classification:

1. Acute
2. Chronic
3. Subluxation
Causes:

1. Over-opening of the mouth to its extreme positions such as during a yawn, hefty laugh or mastication
of large object (biting a full apple).
2. When the jaws are forcibly opened during general anaesthesia, during bronchoscopy or while using a
mouth gag injudiciously.
3. Due to blow on the chin when the mouth is wide open.

Treatment:

A) Acute dislocation can usually be reduced as an outdoor procedure.

Reduction of dislocation of the TMJ:
Have the patient supine
Stand behind the head
Place the thumbs on the posterior teeth and the fingers under the chin
Press increasingly firmly on the posterior teeth while pulling gently up anteriorly
If there is great resistance concentrate on one side at time
When reduced hold the mouth shut for 30 sec or so
Advice restricted mouth opening for at least 24 hours

At times muscle spasm is so strong that it does not allow the manipulation of the condyle back to its original
position, it is advisable to sedate the patient by administration of the muscle relaxant or local anaesthetic
solution or even general anaesthesia can be administered.

B) In majority of the chronic cases, dislocation of long standing usually requires an open reduction.
The patient is taken to the operation theatre and under general anaesthesia jaw is manipulated for closed
reduction.
If it fails, joint is opened through a conventional preauricular approach. The dislocated condyle is
exposed and manipulated under direct vision. The manipulation can be reinforced by exposing the angle of
the mandible through a submandibular incision. A hole is drilled there to facilitate the additional downward
pull with the help of a wire passed through this hole.
 If the above procedure fails, an eminectomy may be performed. This will allow the comfortable
repositioning of the condyle into the fossa since the obstruction stands removed.

Subluxation

It is also known as- Chronic recurrent dislocation

Habitual dislocation
The term should be reserved for repeated episodes of dislocation, where there is abnormal anterior excursion
of the condyle beyond the articular eminence, but the patient is able to manipulate it back into normal
position. So there the condylar head moves unassisted, forward and backward over the articular eminence.
This recurrent incomplete, self-reducing habitual dislocation is termed as hyper mobility or chronic
subluxation of the TMJ.

Causes:

Ligaments and capsular flaccidity

Yawning, vomiting, laughing
Also seen in severe epilepsy and Ehlers-Danlos syndrome

Management:

Intermaxillary fixation or limiting the oral opening by giving elastics for the period of 3-4 weeks.
Patient kept on liquid diet.
Use of sclerosing solution, inject into the joint space.
Ex: Sodium psylliate (not available)
Sodium morrhuate (no good result)
Sodium tetradecyl sulfate (allergic or not recommended)
Surgical procedures:
1. Capsule tightening procedure
2. Creating of a mechanical obstacle
3. Direct restraint of the condyle
4. Creation of a new muscle balance
5. Removal of mechanical obstacle-
Menisectomy
High condylectomy
Eminectomy