Transcript Tempero-mandibular Joint Surgery and Outcomes

Tempero-mandibular Joint
Surgery and Guidelines
PDU 2011
Martin Dodd
TMJ Surgery and Guidelines
• Clinical Anatomy
• Classification of TMJ disorders
• Non Surgical management
• Operative Surgery
• Surgical Complications
• Guidelines/Literature review
Clinical Anatomy of TMJ
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Unique “double” joint
Bone
Synovium
Cartilege
– meniscus
• Ligaments
• Muscle
• Nerve supply
Bone
• Petrous temporal
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Bone
Mandibular condyle
Cartilege
• Tough resilient low
friction surface covers
– the condylar head
– manibular fossa
(glenoid fossa)
– articular eminence
• Meniscus
– Divides joint space
into upper and lower
– Allows translational
movement
Synovium
• Membrane produces
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synovial fluid
Lubricates
Nutrition
Can become
inflammed
Ligaments –stabilise the joint
• Tempero-mandibular
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ligament
Spheno-mandibular
ligament
Stylo-mandibular
ligament
Muscles
• Temporalis
• Masseter
• Medial Pterygoid
– Elevate mandible
• Lateral Ptergoid
– Closes mandible
– Inserts into meniscus
Nerves
• Hilton’s law
Mandibular divison
of the trigeminal
nerve
Masseteric and
auriculotemporal
nerves
TMJ movement
Rotational
Translational
Anatomical relations-surgical
anatomy
Anatomical relations-surgical
anatomy
Conditions affecting the TMJ
• TMJDS
• Osteoarthritis/
• Trauma
• Dislocation/
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osteoarthrosis
Internal derangement
Arthritides
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Rheumatoid
Psoriatic
Seronegative
Reactive
Septic
Subluxation
Tumours
– Primary
benign/maligmant
– Metastatic
• Condylar Hyperplasia
• Ankylosis
Anterior meniscal displacement
Anchored disk phenomenon
Non Surgical management
• Pharmacological
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Analgesics
NSAID’s
Steroids
Botox
“Muscle relaxants”
Non Surgical management
• Physiotherapy
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Exercises
Acupuncture
Heat treatments
TENS
Biofeedback
Massage
• Reassurance/behaviour
modification
Non Surgical management
• Occlusial splint therapy
– Hard
– Soft
– Mandibular advamcement
• OPT
• CT scan (bone
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Imaging
pathology)
MRI (meniscal soft
tissue pathology,
movement disorder)
Isotope bone scan
(Tumours/
hyperplasia
Operative procedures for TMJ
• MUA
• Arthrocentesis
• Arthroscopy
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LESS INVASIVE
Diagnostic
Lysis & lavage
Menisctomy/
Meniscopexxy
Eminectomy
Meniscopexy
Menisectomy+/- flap
TMJ replacement
MORE INVASIVE
Manipulation under anaesthetic
Indications:
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Acute Dislocation
Acute “Closed lock”
Chronic Closed lock
Diagnostic
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Muscular “trismus”
Arthocentesis
Indications:• Acute closed lock
• Anchored disk
phenomenon
• Chronic Closed lock
• Osteoarthritis
• Septic Arthritis
• Inflammatory
arthritides
Arthroscopy
Indications:• Diagnostic
• Acute closed lock
• Anchored disc
phenomenon
• Chronic closed lock
• Intra-articular
adhesions
Eminectomy
Indications
• Recurrent disclocation
• Acute/chronic closed
lock not respnding to
arthrocentesis or
arthroscopy
• In conjunction with
menisectomy/
meniscopexy
TMJ replacement
• Ankylosis
• Tumours
– Benign/(malignant)
• Inflammatory Arthritis
• Previous Failed
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Surgery
Post Traumatic
TMJ Replacements
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Kent prosthesis
Christensen
Lorenz
TMJ concepts
Problems with TMJ replacement
• Infection
• Cost
• “Jelly Joint”
• Revision Surgery
Guidelines
Guidelines AADR
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The AADR recognizes that temporomandibular disorders (TMDs) encompass a group of musculoskeletal
and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles,
and all associated tissues. The signs and symptoms associated with these disorders are diverse, and may
include difficulties with chewing, speaking, and other orofacial functions. They also are frequently
associated with acute or persistent pain, and the patients often suffer from other painful disorders
(comorbidities). The chronic forms of TMD pain may lead to absence from or impairment of work or social
interactions, resulting in an overall reduction in the quality of life.
Based on the evidence from clinical trials as well as experimental and epidemiologic studies:
It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be
based primarily on information obtained from the patient’s history, clinical examination, and when
indicated TMJ radiology or other imaging procedures. The choice of adjunctive diagnostic procedures
should be based upon published, peer-reviewed data showing diagnostic efficacy and safety. However,
the consensus of recent scientific literature about currently available technological diagnostic devices for
TMDs is that, except for various imaging modalities, none of them shows the sensitivity and specificity
required to separate normal subjects from TMD patients or to distinguish among TMD subgroups.
Currently, standard medical diagnostic or laboratory tests that are used for evaluating similar orthopedic,
rheumatological and neurological disorders may also be utilized when indicated with TMD patients. In
addition, various standardized and validated psychometric tests may be used to assess the psychosocial
dimensions of each patient's TMD problem.
It is strongly recommended that, unless there are specific and justifiable indications to the contrary,
treatment of TMD patients initially should be based on the use of conservative, reversible and evidencebased therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to
improve or resolve over time. While no specific therapies have been proven to be uniformly effective,
many of the conservative modalities have proven to be at least as effective in providing symptomatic
relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes,
they present much less risk of producing harm. Professional treatment should be augmented with a home
care program, in which patients are taught about their disorder and how to manage their symptoms.
Note: See website for supporting references at www.aadronline.org/i4a/pages/index.cfm?pageid=3465.
Local-Guidelines
TMJ Referrals
Pain
Trismus
Clicking
Pain
Tender over
TMJ
Intermittant
NO
YES
YES
NO
YES
Tender over
Masseter/
Temporalis/
pterygoid
No
Consider alternate
diagnosis eg,
dental, sinonasal,
neurological or
neoplastic
pathologies
YES
NO
Facial assymetry
Restricted
movement
Tender over
TMJ
YES
No
Dislocation
Reassure
Advise soft diet
Simple analgesics
YES
Referral to Oral &
Maxillofacial Surgery
Does patient
have a dentist
Tender over
masseter/
temporalis/
pterygoid
NO
YES
Yes
Refer to Dentist
For occlusal splint
NO
NO
Reassure/advise
soft diet/simple
analgesics
NO
Review after 6
months if NO
improvement
made
Consider
physiotherapy
Refer to PCT for
NHS Dentist
Ressure patient
no need to refer or
treat
Altered Bite