Professional Documents
Culture Documents
joint disorders
Dr.Neha Sinha
NORMAL ANATOMY
OF TMJ
TEMPOROMANDIBULAR JOINT
Located anterior to the tragus of the ear
Considered an articulation between the base of the skull and the condyle of the
mandible
The articular surface is the squamous part of the temporal bone
Consists of
Articular Fossa (Glenoid Fossa) - Concave
Articular Tubercle or (Eminence) - Convex
Condyle of the mandible
Articular Disc
Joint capsule
Ligaments
CLASSIFICATION OF TEMPORALMANDIBULAR
DISORDERS
1 . MASTICATORY MUSCLE DISORDERS
a) Protective muscle splinting
b) Muscle hyperactivity or spasm
c) Myositis (muscle inflammation)
2. DISK-INTERFERENCE DISORDERS (INTERNAL DERANGEMENTS)
a) In- coordination
b) Deformation of the articular disk
c) Partial anterior disk displacement
d) Anterior disk displacement with reduction
e) Anterior disk displacement without reduction
f) Anterior disk displacement with perforation
g) Posterior disk displacement
3. PROBLEMS THAT RESULT FROM EXTRINSIC TRAUMA
a) Tendonitis
b)Myositis
c) Traumatic arthritis
d)Dislocation
e) Fracture
f) Internal derangement
4. DEGENERATIVE JOINT DISEASE
a) Arthrosis (noninflammatory phase)
b)Osteoarthritis (inflammatory phase)
c) Osteochondritis dissecans or avascular necrosis
5. INFLAMMATORY JOINT DISORDERS
b) Retrodiskitis
c) Inflammatory arthritis
Rheumatoid arthritis
Infectious arthritis
Metabolic arthritis
8. Postsurgical Problems
ARTHRITIS OF THE TEMPOROMANDIBULAR
JOINT
(Inflammation of articular surfaces of joint)
Ref:Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998,85:349.
Disc dislocation
Physiologic disc position
Internal derangement
Classification of the disc displacement based on direction of disc
1: Anterior
2: Anteromedial
3: Medial rotatory
4: Lateral rotatory
5: Anterolateral
6: Medial
7: Lateral
8:Posterior
9: Normal disc position in sagittal oblique closed mouth position on
MRI
Maximum mouth
opening is seen
The clinician right thumb is
placed intraorally over the
paitents left mandibular
second molar and the
mandible is grasped.
With the left hand stabilizing
the cranium gentle but firm
force is applied downward on
the molar and upward on the
chin to distract the joint
Once the joint is distracted the
mandible is brought forward
and to the right enabling the
condyle to move into the area
of dislocated disc.
When this position is achieved
constant distractive force is
applied for 30-40 seconds while
the patient relaxes
After the distraction the
thumb is removed and
that patient is asked to
close on the anterior
teeth maintaining the
jaw in a slightly
protrusive position.
When the patient has
rested a moment the
patient is asked to open
the mouth ,if the disc is
reduced maximal
opening occurs
Supportive treatment
Avoid excessive opening
Soft diet ,Slow chewing
Smaller bites
NSAID in case of inflammation
Heat or ice application
Surgical treatment
A definitive treatment for derangements
It is considered once the conservative
treatment fails
Arthrocentesis
Two needles are placed into the joint and
sterile saline is passed through to lavage the
joint
Lavage is thought to eliminate the algogenic
substances and secondary inflammatory
mediators which causes pain.
Long term effects is positive
Arthrocentesis
In case of disc dislocation without reduction a
single needle can be introduced to the joint
and fluid can be forced into the space in an
attempt to free the articular surfaces.
This technique is called Pumping the joint
It improves the success of manual
manipulation for a closed lock
Arthroscopy
An arthroscope is placed into the superior
joint space and the intracapsular structures
are visualized on the monitor
Joint adhesions can be identified and
eliminated and joint can be significantly
mobilized
It does not correct the disc position instead
success is more likely achieved by improving
the mobility
Arthrotomy
Open joint surgery is called as arthrotomy
When a disc is displaced or dislocated the
most conservative surgical procedure is a
discal repair or plication
During plication a portion of retrodiscal tissue
and inferior lamina is removed and disc is
retracted posteriorly and secured with sutures
Disectomy
Removal of disc causes bone to bone contact
and causes osteoarthritic changes
Silastic has been placed in place of the disc
Proplast Teflon discal implants have been used
but it leads to inflammatory reaction.
Dermal temporal fascial flaps and auricular
cartilage grafts have also been used
Complications of surgery
Scarring restricts mandibular movements
Post surgical adhesions
Facial nerve damage
Trauma affecting TMJ
FRACTURES
Fractures of the condylar head and neck often
result from a
blow to the chin .
The patient with a condylar fracture usually
presents with pain and edema over the joint
area and limitation and deviation of the
mandible to the injured side on opening.
Bilateral condylar fractures may result in an
anterior open bite.
Fracture of condyle
The diagnosis of a condylar fracture is
confirmed by radiographic examination.
Intracapsular nondisplaced fractures of the
condylar head are usually not treated
surgically.
Early mobilization of the mandible is
emphasized to prevent bony or fibrous
ankylosis.
Classification of condylar neck fractures
(Spiessl and Schroll)
Classification
Type I: Virtual fracture of neck but without
displacement
Type II: Lower neck fracture with displacement
Type III: Fracture high on the neck with
anterior,posterior,medial or lateral displacement
Type IV: Lower neck fracture with separation
Type V: High neck fracture with displacement
Type VI: Fracture of head of the condyle within the
capsule
Ref:Colour atlas of Tmj and Orofacial pain: Wolf
Condylar neck fracture
Condylar fracture
Developmental disorders of TMJ
Common growth disturbances of the bones
include
1: Agenesis
2: Hypoplasia
3: Hyperplasia
4: Neoplasia
Congenital and Developmental bone
disorders
Agenesis of condyle
Hyperplasia of condyle
True condylar hyperplasia usually occurs after
puberty and is completed by 18 to 25 years of age.
Limitation of opening,deviation of the mandible to
the side of the enlargedcondyle, and facial
asymmetry may be observed.
Pain is occasionally associated with the hyperplastic
condyle on opening.
(Management of tmj disorders and occlusion.Jeffrey Okeson.)
Hyperplasia of condyle
Facial asymmetry often results from disturbances in
condylar growth because the condyle is considered
to be a site for compensatory growth and adaptive
remodeling.
The facial deformities associated with condylar
hyperplasia involve the formation of a convex ramus
on the affected side and a concave shape on the
normal side.
If the condylar hyperplasia is detected and surgically
corrected at an early stage, the facial deformities
may be prevented.
Condylar hyperplasia
From the literature
An increased uptake of Technetium 99 as
determined by gamma scintigraphy in patients
with condylar hyperplasia