tmj
TRANSCRIPT
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TEMPOROMANDIBULA
R
JOINT
By – Dr. JJ
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Contents INTRODUCTION PECULIARITY OF TMJ COMPONENTS VASCULAR SUPPLY INNERVATIONS RELATIONS MOVEMENTS AGE CHANGES DEVELOPMENT CLINICAL SIGNIFICANCE TMJ DISORDERS CONCLUSION REFERENCES
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JOINTS
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CLASSIFICATIONS OF JOINTS
STRUCTURAL CLASSIFICATION:
FIBROUS JOINTCARTILAGENOUS JOINTSYNOVIAL JOINT
FUNCTIONAL CLASSIFICATION:
SYNARTHROSIS AMPHIARTHROSESDIARTHROSIS
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TEMPOROMANDIBULAR JOINT
The TMJ is a ginglymoarthrodial joint, a term
that is derived from ginglymus, meaning a
hinge joint, allowing motion only backward
and forward in one plane, and arthrodia,
meaning a joint of which permits a gliding
motion of the surfaces.
Dorland WA: Medical Dictionary. Philadelphia and London, SaundersCo., 1957
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The temporomandibular joint (TMJ), also known as the mandibular joint, is an ellipsoid variety of the right and left synovial joints forming a bicondylar articulation.
The common features of the synovial joints exhibited by this joint include a disk, bone, fibrous capsule, fluid, synovial membrane, and ligaments. However, the features that differentiate and make this joint unique are its articular surface covered by fibrocartilage.
Williams PL: Gray’s anatomy, in Skeletal System (ed 38). Churchill. Livingstone, London, 1999, pp 578-582
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Peculiarity of TMJ
1. Bilateral diarthrosis – right & left function
together
2. Articular surface covered by fibrocartilage
3. Only joint in human body to have a rigid
endpoint of closure that of the teeth making
occlusal contact.
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4. In contrast to other diarthrodial joints TMJ is
last joint to start develop, in about 7th week in
utero.
5. Develops from two distinct blastema.
Peculiarity of TMJ…….
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COMPONENTS
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COMPONENTS OF THE TMJMANDIBULAR CONDYLES
ARTICULAR EMINENCE
MUSCLES OF THE TMJ:
MUSCLES OF MASTICATION
SOFT TISSUE COMPONENTS:
ARTICULAR DISC
JOINT CAPSULE
LIGAMENTS
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THE MANDIBULAR CONDYLE
An ovoid process seated atop a narrow mandibular neck. It’s the articulating surface of the mandible.
It is convex in all directions but wider latero-medially (15 to 20 mm) than antero-posteriorly (8 to 10mm).
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It has lateral and medial poles:
The medial pole is directed more posteriorly.
Thus, if the long axes of two condyles are extended medially, they meet at approximately the basion on the anterior limit of the foramen magnum, forming an angle that opens toward the front ranging from 145° to 160°
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Cranial Componentor
Articular surfaces of Temporal bone
The articular surface
of the temporal bone
is situated on the
inferior aspect of
temporal squama
anterior to tympanic
plate.
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Articular eminence: This is the entire transverse bony bar that forms the anterior root of zygoma. This articular surface is most heavily traveled by the condyle and disk as they ride forward and backward in normal jaw function.
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Articular Disc
The articular disc is the most important anatomic structure of the TMJ.
It is a biconcave fibrocartilaginous structure located between the mandibular condyle and the temporal bone component of the joint.
Its functions to accommodate a hinging action as well as the gliding actions between the temporal and mandibular articular bone.
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The articular disc is a roughly oval, firm, fibrous plate.
• It is shaped like a peaked cap that divides the joint into a larger upper compartment and a smaller lower compartment.
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Hinging movements take place in the lower
compartment and gliding movements take
place in the upper compartment.
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The disc is attached all around the joint
capsule except for the strong straps that fix
the disc directly to the medial and lateral
condylar poles, which ensure that the disc
and condyle move together in protraction
and retraction.
Williams PL: Gray’s anatomy, in Skeletal System (ed 38). ChurchillLivingstone, London, 1999, pp 578-582
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Fibrous Capsule
Thin sleeve of tissue completely surrounding the joint.
Extends from the circumference of the cranial articular surface to the neck of the mandible.
Patnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint A review. J Anat Soc India 49(2):191-197, 2010
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Anteriorly, the capsule has an orifice through
which the lateral pterygoid tendon passes. This
area of relative weakness in the capsular lining
becomes a source of possible herniation of intra-
articular tissues, and this, in part, may allow
forward displacement of the disc.
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Temporomandibular Ligaments Complex
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Collateral Ligaments
The ligament on each side of the jaw is designed in two distinct layers.
The wide outer or superficial layer is usually fan-shaped and arises from the outer surface of the articular tubercle and most of the posterior part of the zygomatic arch.
There is often a roughened, raised bony ridge of attachment on this area.
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Sphenomandibular Ligament
Arises from the angular spine of the sphenoid and petrotympanic fissure.
Runs downward and outward.
Insert on the lingula of the mandible.
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The ligament is related –1. Laterally - lateral pterygoidmuscle.2. posteriorly - auriculotemporal
nerve.3. anteriorly - maxillary artery.4. Inferiorly - the inferior alveolar
nerve and vessels a lobule of the parotid gland.
5. Medially - medial pterygoid with the chorda tympani nerve and the wall of the pharynx with fat and the pharyngeal veins intervening.
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The ligament is pierced by the myelohyoid nerve and vessels.
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Stylomandibular Ligament
This is a specialized dense, local concentration of
deep cervical fascia extending from the apex and
being adjacent to the anterior aspect of the styloid
process and the stylohyoid ligament to the
mandible’s angle and posterior border.
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Other ligaments
Oto mandibular ligament Disco malleolar ligament Mallelo mandibular ligament
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Lubrication of the Joint
The synovial fluid comes from two sources:
first, from plasma by dialysis, and second, by
secretion from type A and B synoviocytes with a
volume of not more than 0.05 ml.
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Synovial fluid…… It is clear, straw-colored viscous fluid. It diffuses out from the rich cappillary
network of the synovial membrane.
Contains: Hyaluronic acid which is highly viscous May also contain some free cells mostly
macrophages.
Functions: Lubricant for articulating surfaces. Carry nutrients to the avascular tissue of the
joint. Clear the tissue debris caused by normal
wear and tear of the articulating surfaces.
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Muscular Component The masticatory muscles surrounding the joint are
groups of muscles that contract and relax in harmony so that the jaws function properly.
When the muscles are relaxed and flexible and are not
under stress, they work in harmony with the other parts of the TMJ complex.
The muscles of mastication produce all the movements of the jaw.
These muscles begin and are fixed on the cranium extending between the cranium and the mandible on each side of the head to insert on the mandible.
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MUSCLES OF MASTICATION
Moves mandible - mastication &
speech
1.Masseter
2.Temporalis
3.Lateral pterygoid
4.Medial pterygoid
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MUSCLES – INSERTION – NERVE SUPPLY- ACTIONS
Masseter superficial layer Elevates
middle layer mandible deep layer
Temporalis temporal fossa elevates
temporal fascia grinding
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MUSCLES – INSERTION – NERVE SUPPLY - ACTION
Lateral pteryoid upper head depression
lower head protrusion grinding
Medial pterygoid superficial head elevates
deep head protrusion
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Teeth and Occlusion
The way the teeth fit together may affect the TMJ complex.
A stable occlusion with good tooth contact and interdigitation provides maximum support to the muscles and joint, while poor occlusion (bite relationship) may cause the muscles to malfunction and ultimately cause damage to the joint itself.
Instability of the occlusion can increase the pressure on the joint, causing damage and degeneration.
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VASCULARISATION
Branches of External Carotid Artery Superficial temporal artery Deep auricular artery Anterior tympanic artery Ascending pharyngeal artery Maxillary artery
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VASCULARISATION
The Blood supply to TMJ is only Superficial, i.e. there is no blood supply inside the capsule.
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Innervation
Sensory innervation of the TMJ
is derived from the
auriculotemporal and
masseteric branches of
trigeminal nerve.
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LYMPHATIC DRAINAGE
LATERAL SURFACE : PREAURICULAR AND
PAROTID NODES
POSTERIOR AND MEDIAL SURFACE : SUBMANDIBULAR NODES THROUGH
EXTERNAL CAROTID ARTERY
ANTERIOR SURFACE : PAROTID NODES
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RELATIONS
Anteriorly - Mandibular notch Lateral pterygoid Masseteric nerve and artery
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RELATIONS
Posteriorly - parotid gland Superficial temporal vessels Auriculotemporal nerve
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RELATIONS
Laterally –
Skin and fasciaParotid glandTemporal branches of facial nerve
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Medially - Tympanic plate (separates from ICA) spine of sphenoid Auriculotemporal & chorda tympani nerve middle meningeal artery maxillary artery
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Superiorly –middle cranial fossamiddle meningeal vessels
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Inferiorly – maxillary artery & vein
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MOVEMENTS OF TMJ
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Movements
Rotational / hinge movement in first 20-25mm of mouth opening.
Translational movement after that when the mouth is excessively opened.
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Translatory movement – in the superior part of the joint as the disc and the condyle traverse anteriorly along the inclines of the anterior tubercle to provide an anterior and inferior movement of the mandible.
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Mouth closed Mouth open
Hinge movement – the inferior portion of the joint between the head of the condyle and the lower surface of the disc to permit opening of the mandible.
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1. Depression Of Mandible Lateral pterygoid Digrastric Geniohyoid Mylohyoid
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2. Elevation of Mandible Temporalis Masseter Medial Pterygoids
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3. Protrusion of Mandible Lateral Pterygoids Medial Pterygoids
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4. Retraction of Mandible Posterior fibres of Temporalis
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Age changes of the TMJ: Condyle:
Becomes more flattened Fibrous capsule becomes thicker. Osteoporosis of underlying bone. Thinning or absence of cartilaginous zone.
Disk: Becomes thinner. Shows hyalinization and chondroid changes.
Synovial fold: Become fibrotic with thick basement membrane.
Blood vessels and nerves: Walls of blood vessels thickened. Nerves decrease in number.
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These age changes lead to:
Decrease in the synovial fluid formation.
Impairment of motion due to decrease in the disc and capsule extensibility.
Decrease the resilience during mastication due to chondroid changes into collagenous elements.
Dysfunction in older people.
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DEVELOPMENT
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The mandible develops from Meckel’s
cartilage, which provides the basic support
for the lower jaw and terminates dorsally
into Malleus.
The primary joint exists till the 4th month of
intra uterine life.
At 3 month of gestation the secondary joint
begins to form
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Embryologically, the primary jaw joint
between incus & malleus persists in
the fetal period till 4 months of IUL.
It is then replaced by secondary joint,
as incus & malleus recede into middle
ear and initiate sound conduction.
It is phylogenetically replaced by
secondary joint, which is the TMJ.
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HISTOLOGY OF TMJ
BONY STRUCTURES:
Condyle- composed of cancellous bone
covered by a thin compact bone
- trabeculae radiate from neck of condyle
Fossa- roof consists of thin layer of
compact bone
Articular eminence- spongy bone
covering thin layer of compact bone
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Fibrocartilagenous zone:
- Collagen fibers in bundles forms net work
- resist compressive & lateral forces
Calcified zone:
- deepest zone,chondrocytes &
chondroblasts
- active site for remodelling
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Clinical significance
Examination
Disorders
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Examination
To palpate the joint and its associated
muscles effectively, have the patient go
through all the movements of the mandible
in relationship to the TMJ while bilaterally
palpating the joint just anterior to the
external acoustic meatus of each ear.
65
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This includes asking the patient to open
and close the mouth several times and
then to move the opened jaw to the
left, and then to right, and then
forward.
To further assess the mandible moving
at the TMJ, use digital palpation by
gently placing a finger into the outer
part of EAM.
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TMJ DISORDERS
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Temporomandibular Joint Disorder
• The disorder and resultant dysfunction can result in significant pain and impairment
• Because the disorder transcends the boundaries between several health-care disciplines in particular,
- Dentistry - Neurology - Physical therapy - Psychology
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CLASSIFICATION OF DISORDERS OF TMJ
1. Masticatory Muscle Disorders
a. Protective co-contraction b. Local muscle soreness c. Myofascial pain d. Myospasm e. Centrally mediated myalgia
2. Temporomandibular Joint Disorders A. Derangement of condyle-disc complex a. Disc displacements b. Disc dislocation with reduction c. Disc dislocation without reduction
B. Structural incompatibility of the articular surfaces a. Deviation in form - Disc - Condyle - Fossa b. Adhesions - Disc to condyle - Disc to fossa
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c. Subluxation ( hypermobility)d. Spontaneous dislocation
C. Inflammatory Disorders of TMJ a. Synovitis b. Retrodiscitis
c. Arthritides - Osteoarthritis - Osteoarthrosis - Polyarthritides d.. Inflammatory disorders of associated structures a. Temporal tendonitis b. Stylomandibular ligament inflammation
3. Chronic mandibular hypomobility A. Ankylosis - Fibrous - Bony B. Muscle contracture - Myostatic - Myofibrotic C. Coronoid impedance
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4. Growth Disorders A. Congenital and developmental bone
disorders a. Agenesis b. Hypoplasia c. Hyperplasia d. Neoplasia
B. Congenital and developmental muscle disorders
a. Hypotrophy b. Hypertrophy c. Neoplasia
.
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Predisposing Factors
• Modification of chewing surfaces of the teeth through dental neglect or accidental trauma
• Speech habits resulting in jaw thrusting.
• Excessive gum chewing or nail biting.
• Excessive jaw movements associated with exercise.
• Repetitive subconscious jaw movements associated with bruxing or clenching.
• Size of foods eaten
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Signs and Symptoms
• Jaw pain and/or stiffness
• Headaches, usually at the temples and side of head.
• Vague tooth soreness or toothache which often move around the mouth.
• Sensitive teeth
• Painful or tender jaw joint
• Difficulty in opening jaw and ear pain.
• Pain and fatigue when eating hard or chewy foods
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Treatment
TMD treatments are conservative and reversible
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Treatment
Conservative Treatments
• Conservative treatments are as simple as
possible and are used most often because most
patients do not have severe, degenerative TMD
• Conservative treatments do not invade the tissues
of the face, jaw or joint
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Treatment
Reversible treatments do not cause permanent, or
irreversible, changes in the structure or position of the
jaw or teeth.
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TMJ Symptom Relief
• It is important to avoid large movement of the jaw
such as singing
and wide yawning.
• Do not apply pressure with your hand against your jaw
for an extended time period during sleep.
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TMJ Symptom Relief
Choose soft food and stay away from foods requiring
repetitive chewing or the mouth to open wide. In
particular, avoid chewing gum and raw carrots.
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TMJ Symptom Relief
Continue to receive dental treatment for any teeth
requiring restoration. Tooth decay may affect the bite,
a contributing factor to TMJ..
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TMJ Symptom Relief
Medications • Non-steroidal anti-inflammatory drugs (NSAIDs like ibuprofen), muscle relaxants, anti-anxiety medications and in some cases anti-depressants.
• The choice of medication depends on the intensity of the disorder and the medical history.
• However, the need for medication is greatly reduced when treatment is received by an experienced TMJ dental professional.
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Dental Appliances
TMJ Symptom Relief
• Dentist may prescribe a dental appliance such as
a mouth guard or splint to reduce the effects of
tooth grinding and clenching.
• Such appliances may also help improve your bite
and the ability for the lower jaw to fall properly into
the temporomandibular joint socket.
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MOST COMMON TMDs
Myofascial pain and dysfunction Internal derangement Osteoarthrosis Dislocation
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MYOFASCIAL PAIN AND DYSFUNCTION
Refers to a group of poorly defined muscle
disorders (eg, fibromyalgia) characterized by
diffuse facial pain and episodic limited jaw opening.
May result from parafunctional habits and
significant relationship to psychophysiologic
disorders such as stress or depression.
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INTERNAL DERANGEMENT
Abnormal relationship of the articular disc to
the mandibular condyle, fossa,and articular
eminence, interfering with the smooth action
of the joint (Dolwick 1983).
Is a localized mechanical fault within the
joint.
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OSTEOARTHROSIS
Is a non- painful, localized degenerative joint disease
that mainly affects bone and articular cartilage.
It is often idiopathic, but predisposing factors such
as old age, repetitive trauma (bruxism), abnormal
joint posturing, or multiple surgical procedures may
be involved. If painful, then referred to as
osteoarthritis.
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ANKYLOSIS
Fusion of the TMJ is the occasionallate outcome of trauma or infection.
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Dislocation
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EPIDEMIOLOGY TMD mostly affects people in the 20 – 40 age
group, and the average age is 33.9 years.
About 60-70% of the population have
features of TMDs.
About 20-30% report symptoms of TMDs.
About 5% of people with TMD symptoms
actually seek treatment.
The female: male ranges from 3:1• Natl J Maxillofac Surg. 2014 Jan-Jun; 3(1): 25–30.• Prevalence of Temporo-mandibular Joint Disorders in
Symptomatic and Asymptomatic Patients: Int J Adv Sci 2014; 1(6): 14-20
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TMJ SURGERY
Indicated for a subset of temporomandibular disorders:
1.Internal derangment; 2.Degenerative joint disease; 3. Rheumatoid arthritis; 4. Infectious arthritis; 5.Mandibular dislocation; 6.Ankylosis; 7.Condylar hyper/hypoplasia
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Examples of surgical procedures that are used in
TMD, arthrocentesis, arthroscopy,
menisectomy, disc repositioning, condylotomy
or joint replacement.
Invasive surgical procedures in TMD may cause
symptoms to worsen.
Menisectomy, also termed discectomy refers to
surgical removal of the articular disc.
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SURGERIES OF THE JOINT
Discectomy Disc repositioning Condylotomy Arthrocentesis Arthroscopy Partial and total joint replacement
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Conclusion
• TMJ plays important role in chewing ,
speaking, swallowing etc.
• It is one of most important and most poorly understood of the many joints in the body.
• We are just now beginning to understand it
and give it the respect and careful treatment it
deserves as an integral functioning part of the
dental anatomy.
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REFERENCES - TEXTBOOK
1. Sicher and Dubrul's Oral Anatomy by E. Lloyd Dubrul2. The Tmj Book by Andrew S. Kaplan, Jr. Williams Gray 3. B.D. Chaurassia’s human anatomy 4th edition vol. 3 The Head &
Neck.
4. Williams PL: Gray’s anatomy, in Skeletal System (ed 38). Churchill Livingstone, London, 1999, pp 578-582
5. Fonseca volume 2 by Robert D. Marciani6. Temporomandibular Disorder, A Problem Based
Approach by Dr Robin J. M. Gray & Dr M. Diad Al – Ani7. Surgical Approaches To Facial Skeleton By – Edward
Ellis III & Nmichael F. Zide8. Surgery Of TMJ 2nd ed. by David A. Keith
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REFERENCES - ARTICLES1. Dorland WA: Medical Dictionary. Philadelphia and London, Saunders Co.,
19572. Williams PL: Gray’s anatomy, in Skeletal System (ed 38). Churchill
Livingstone, London, 1999, pp 578-5823. Yale SH: Radiographic evaluation of the temporomandibular joint. J Am
Dent Assoc 79(1):102-107, 19694. Patnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint?
A review. J Anat Soc India 49(2):191-197, 20005. Harms SE, Wilk RM: Magnetic resonance imaging of the
temporomandibular joint. Radiographics 7(3):521-542, 19876. Tallents RH, Katzberg RW, Murphy W, et al: Magnetic resonance imaging
findings in asymptomatic volunteers and symptomatic patients with temporomandibular disorders. J Prosthet Dent 75(5):529-533, 1996
7. Helms CA, Kaplan P: Diagnostic imaging of the temporomandibular joint: recommendations for use of the various techniques. AJR Am J Roentgenol 154(2):319-322, 1990
8. Helms CA, Kaban LB, McNeill C, et al: Temporomandibular joint: morphology and signal intensity characteristics of the disk at MR imaging. Radiology 172(3):817-820, 1989
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REFERENCES - ARTICLES
9. Kreutziger KL, Mahan PE: Temporomandibular degenerative joint disease. Part II. Diagnostic procedure and comprehensive management. Oral Surg Oral Med Oral Pathol 40(3):297-319, 1975
10. Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg 11(3):207-212, 1974
11. McMinn, RMH: Last’s anatomy regional and applied, in Head and Neck and Spine. Churchill Livingstone, Edinburgh, London, 1994, p. 523
12. Roberts D, Schenck J, Joseph P, et al: Temporomandibular joint: magnetic resonance imaging. Radiology 154(3):829-830, 1985
13. Harms SE, Wilk RM, Wolford LM, et al: The temporomandibular joint: magnetic resonance imaging using surface coils. Radiology 157(1):133- 136, 1985
14. Edelstein WA, Bottomley PA, Hart HR, et al: Signal, noise, and contrast in nuclear magnetic resonance (NMR) imaging. J Comput Assist Tomogr 7(3):391-401, 1983
15. Westesson PL, Katzberg RW, Tallents RH, et al: Temporomandibular joint: comparison of MR images with cryosectional anatomy. Radiology 164(1):59-64, 1987
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PREVIOUS YEAR QUESTIONS
Muscles of Mastication (RGUHS 2007,20 marks)
Temporomandibular joint (RGUHS 2005, 10 marks)