Transcript Lecture TMJ Disorders File

COMMON TMJ
DISORDERS/DYSFUNCTION
BDS5 ORAL SURGERY 2014
DR KANTARA TIIM
CMNHS
FNU
Anatomy Revision
Mouth Opening
Muscular Action: Open/Close
Temporalis
Medial Pterygoid
Masseter
Lateral pterygoids
Geniohyoid
Mylohyoid
Anterior belly of digastric
TOPICS
1. Myofascial Pain Dysfunction
2. Anterior Disc Displacement
3. TMJ dislocation
1. MYOFASCIAL PAIN DYSFUNCTION
 Clinical Features
- Affects muscles only: neck, scalp,
masticatory
- Predominantly in young
- Affects women more than men
Signs & Symptoms
• Pain
– Muscles painful during use, often painful in morning
– Specific tender spots on muscle
– Masticatory muscles may be tender to palpation
•
•
•
•
•
Clicking
Jaw locking
Limitation of mouth opening/jaw movements
Develops over weeks to months
Condition self limiting: few wks – few years
Aetiology
Several contributing factors
 Parafunctional activity e.g. clenching,
grinding
 Stress, psychological disturbance or
psychiatric illness
 Occlusal disturbance
 Wide opening of mouth
 True joint disease in TMJ
 Other local inflammatory conditions
Treatment
 Reassurance/explanation of the benign and selflimiting nature of the problem
 Minimizing chewing (e.g. soft diet and limitation of
movement)
 Watch and control daytime parafunction
 Anti-inflammatory analgesic (e.g.ibuprofen 400 mg
three times a day)
 Occlusal splint therapy esp. at night
 Local physiotherapy
 Consider referral to psychologist/psychiatrist (if
suspect severe anxiety/depression, psychiatric
disturbance)
2. ANTERIOR DISC DISPLACEMENT
 Classifications
2.1 Disc displacement with reduction
2.2 Disc displacement without
reduction
2.3 Disc adhesion
Anterior Disc Displacement
Aetiology
 Traumatic injuries
 Chronic joint compressions (tooth
grinding and clenching)
2.1 Disc displacement with reduction
 Anteriorly displaced disc that
returns to normal position during
mouth opening
 Makes a Clicking noise
2.1 Disc displacement with reduction cont’d
TMJ Clicking
2.2 Disc displacement without reduction
 Anteriorly displaced disc does not
return to normal position during
mouth opening
 TMJ locking
2.2 Disc displacement without reduction
cont’d
TMJ locking
2.3 Disc adhesion
 Adhesion of the disc to the joint socket
 Occur most often in the upper joint space and can
result from 2 mechanisms:
- Synovitis  fibrin layer (instead of hyaluronic
acid) causing fibrous tissue  disc adhesion
- Hematoma  healing with capillary invasion 
transition to scar-like fibrous tissue
 Locking
2.3 Disc adhesion cont’d
Disc adhesion
DIAGNOSIS DEPENDS ON:
1. Range of motion
2. Assessment of TMJ function
3. Palpation of muscles and joints
1. Range of Motion
• Measured from incisal edge of uppers to
incisal edge of lower central incisors (11/41
or 21/31)
•
•
•
•
Normal opening = 40mm
Lateral excursion = 7mm - 10mm
Normal protrusion = 6mm - 9mm
Non painful
Limitation in Range of Motion
• Muscle “spasm” - jaw closing muscles
• Non reducing anteriorly displaced disc (closed
lock???)
• Interference in the coronoid process
• Fibrous ankylosis of the joint
• Joint inflamation
• Haematoma
• Neoplasm
• Infection
Deviation in mouth opening
Deviates to affected
side of the click and
returns to centre
No limitation in mouth
opening
Deviates to side of disc
displacement
Does not correct itself
Limitation in mouth
opening
2. Assessment of TMJ Function –
TMJ Sounds
• Detected by palpation or auditory
• Repetitive open/close and lateral/protrusive
movements
• Clicking, crepitus, “cluncking”
• Not an indication for treatment unless
associated pain or dysfunction
3. Palpation of muscles & joints
• Tenderness in joints, muscles,
associated structures
• Myofascial pain
• Trigger points
Treatment: Anterior Disc Displacement
TMJ clicking?
 Treated only when painful and socially
unacceptable
 Medical treatment of painful TMJ
clicking:
- Medications for relief of pain (NSAID’s)
- Soft, non-chewy diet
- Use of an occlusal splint to prevent
chronic tooth clenching and chewing
Treatment: Anterior Disc Displacement cont…
TMJ clicking?
• Surgical treatment of painful TMJ clicking:
- arthroscopic surgery of the disc
- discoplasty (surgical disc repositioning)
3.TMJ DISLOCATION
Classifications
1. Acute Dislocation
Usually managed by manual reduction
2. Chronic Recurrent
3. Chronic Persistent
2 & 3 are likely to be managed by surgical
intervention
Classification of Anterior TMJ Dislocation
• Dislocation classified based on relationship of the
head of mandibular condyle to the articular
eminence seen on clinico-radiological evaluation
into three types (I-III).
• Type I - the head of condyle is directly below the
tip of the eminence
• Type II - the head of condyle is in front of the tip
of the eminence
• Type III - the head of condyle is high up in front of
the base of the eminence.
Clinical Features
• Open mouth
• Symmetrical: bilateral TMJ dislocation
• Non-symmetrical: Unilateral
dislocation
Conservative Treatment:
Manual Reduction with/without
sedation/GA
Surgical Interventions
• To reposition condyle in fossa (There was
much restriction of movement)
e.g. Temporalis myotomy, Coronoidectomy or
both
• To correct fusion and restore the joint (There
was complete restriction of movement)
e.g. Low Condylectomy
Surgical Interventions cont..
• To restrict condylar movement
e.g. Lateral pterygoid myotomy
• To recreate mechanical obstruction along
condylar path
e.g. Downward and inward fracture of zygomatic
bone
e.g. Eminoplasty with onlay bone gafts (Dautery
procedure)
Surgical Interventions cont..
• To remove mechanical obstacle along condylar
path
e.g. Eminectomy
References
1.
2.
3.
4.
Akinbami, B.O. (2011), Evaluation of the mechanism and principles of
management of temporomandibular joint dislocation. Systematic review
of literature and a proposed new classification of temporomandibular
joint dislocation, Head & Face Medicine 2011, 7:10
Scully,C. and D. H. Felix, D.H. (2006) , Oral Medicine — Update for the
dental practitioner Orofacial pain, British Dental Journal Vol. 200 (2):7583
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