temporomandibular disorders
TRANSCRIPT
Introduction
• Routine practice TMD are common
• TMD are multi-factorial, avoid tunnel
vision
• TMJ, masticatory muscles and teeth
should not be considered in isolation.
• Dental treatment for 18 months
• General practitioner
• ENT consultant
• Neurologist
• Clinical psychologist
• Psychiatrist
• Restorative dentist
• General dental practitioner
• Three third molars removed
• Two apicoectomies done
• Four root canal treatments
• Symptoms unchanged
• TMJ clinic
• Minor occlusal correction
Functional Anatomy
• Ginglymodiathrodial joint
• Boney components enclosed and connected by fibrous capsule
• Capsule lined with synovium
• Joint cavity filled with synovial fluid
• Fluid decreases friction
Articular Disc
• Space between condyle and mandiular fossa
is occupied by collagenous fibrous tissue
• Disc is attached to the lateral and medial
poles of the condyle by ligaments
• Thick in the centre and thin on both the ends.
• Avascular and little sensory nervous
penetration
• Divides joint to U/L compartments
• Retrodiscal tissue
• Temporomandibular ligament
• Capsular ligament
Muscles of mastication
• Massater
• Medial pteygoid
• Lateral pterygoid
• Temporalis
• Accessory muscles
• Vascular– External carotid artery
• Nerve supply– Trgeminal nerve– Cranial nerve VII, IX, X, XI
2
• Etiology
• Epidemiology
• Classification
Etiology
• Occlusal disharmony
• Psychological distress
• Parafunctional habits
• Emotional distress
• Acute trauma from blows or impacts
• Trauma from hyperextensions
• Instability of maxillo-mandibular reln
• Laxity of joint
• Rheumatic disorders (comorbidity)
• Poor general health
Epidemiology
• Age 20 – 40 Yrs
• Predominantly women
• 65 – 85% of the population
• 12% prolonged pain
• 5 – 7% need treatment.
Classification
• Cranial bones– Congenital and developmental– Fracture– Neoplasia
Muscles– Myofascial pain– Myositis
• Temporomandibular joint– Disc displacement– Dislocation– Inflammation– Arthritis– Neoplasia– Ankylosis
Assessment
• History
• Physical examination
• Imaging
History
• Apart from routine history, dental, medical and drug history
• PAIN is most important feature
• Pain diary could be maintained
Physical examination
• Mandibular movements– Opening– Lateral– Protrusive– Deviation
• Tenderness in muscles of mastication
Imaging
• Plain film radiographs
• Arthrography
• Tomography
• Computed tomography
• Magnetic resonance imaging
Intracapsular Disorders
• Articular disc disorders– With or without symptoms
• Arthritis– With or without symptoms
Articular disc displacement
• Abnormal relationship of disc with its surrounding structures
• Due to stretching or tearing of attachment to condyle and glenoid fossa
• Abnormal joint sounds
• Limitation in mandibular range of motion
• Pain during mandibular movement
• Majority of cases of ADD occur without significant pain or joint dysfunction.
Contd…
Etiology
• Direct trauma to the joint
• Chronic low-grade microtrauma
• Craniofacial morphology
• Anterior disk displacement with
reduction (clicking joint)
• Anterior disk displacement without
reduction (closed lock).
• ADD with reduction– Common, need no treatment but for pain
• ADD without reduction– After trauma or nocturnal bruxism
Management
• Resolve with time
• Conservative treatment
• Techniques to reduce discomfort
• Disc will remain displaced
Osteoarthritis
• Disorder of articular cartilage and subchondral bone
• Secondary inflammation of the synovial membrane.
• Response of the joint to chronic microtrauma or pressure.
CLINICAL MANIFESTATIONS
• Over the age of 20 years.
• Incidence increases wiath age
• Unilateral pain directly over the condyle
• Limitation of mandibular opening
• Crepitus
• Feeling of stiffness after a period of inactivity
Radiographic findings
• Narrowing of the joint space
• Irregular joint space
• Flattening of the articular surfaces
• Osteophytic formation
• Anterior lipping of the condyle
Management
• NSAID
• Hot moist fomentation
• Soft diet
• Rest
• Occlusal splints
Myofascial Pain Dysfunction Syndrome
Etiology
• Masticatory muscle spasm
• Improper restoration
• Grinding or Clenching
– Psycho-physiologic theory
Leads to…
• Pain
• Limitation of motion
• Minor shift in the jaw rest position
• When spasm is relieved patient develops occlusal imbalance
• Degenerative arthritis & muscle contracture
• Amplification of original spasm
Clinical symptoms
• Pain
• Muscle tenderness
• Clicking or popping noise
• Limitation of jaw motion
Negative findings
• Absence of changes in the joint– Clinical– Roentgenographic
• Lack of tenderness in joint
Diagnostic Imaging
Is of value in selected conditions but not as a
part of a standard assessment , should be
considered only when clinical presentation
suggests a progressive pathologic condition
like osteodegenerative disease, fractures or
tumors of bone.
Tomograms for evaluation of bony structures
MRI for evaluation of soft tissue
Imaging Options
• Radiographs– OPG– Extra oral views
• Arthrography
• CT
• MRI
• Bone scan
• 3 D reconstruction from CT, MRI
Radiographs
Transorbital View
Transpharyngeal View
OPG
OPG
Degenerative osteoarthritis TMJ Tomogram
Normal TMJ Tomogram
Degenerative osteoarthritis with osteophyte TMJ Tomogram
MRI
Treatment
• Education & Information
• Self-care & Habit reversal
• Physiotherapy
• Intraoral appliances
• Pharmacotherapy
• Behavioural therapy & Relaxation technique
• Trigger point therapy