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Pathology and Medical Management TMJ Disorders and Diseases

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Presentation on theme: "Pathology and Medical Management TMJ Disorders and Diseases"— Presentation transcript:

1 Pathology and Medical Management TMJ Disorders and Diseases

2 Symbols this is for your information only,
it won’t be used for the exam important to know for exam

3 Temporomandibular Joint Imaging
Radiography: Fractures which might occur. Can also get an idea of the joint position Generally not as useful as other types of imaging studies Standard Views: Transcranial View Submentovertex view Cephalometry: lateral views MRI: T1-weighted sagittal images are the method of choice for TMJ examination. Articular disk position T2 weighted images Periarticular changes Joint effusions CT

4 Figure 5.  a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position.
Figure 5.  a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position. 1, Mandibular head; 2, articular fossa; 3, disk (3a, anterior band; 3b, intermediate zone; 3c, posterior band); 4, bilaminar zone; 5, lateral pterygoid muscle. Sommer O J et al. Radiographics 2003;23:e14-e14 ©2003 by Radiological Society of North America

5 TMJ Dysfunctions Articular Non Articular Non-Inflammatory Inflammatory
MPDS Articular Disk Displacement Synovitis and Capsulitis Myositis With Reduction Spasm Arthritic Disorders Without Reduction Muscle Contracture Osteoarthritis Deviation in Form Rheumatoid Arthritis Dislocation and Subluxation Other Ankylosis Bony Fibrosis

6 Articular Disk Displacements with Reduction
Partial Anteromedial Disk Displacement Disk slides anterior on the condyle Posterior band is more anteriorly placed than normal Etiology: Thinning of the posterior band Minimal elongation of diskal ligaments TX: intro-oral appliances in combination with stress reduction Condlye always on disk. Displacement is that the condyle has slipped off the condyle Reduction the condyle moves back on to disk = this will have noice (clicks, crakles)

7 Disk Displacement Anteromedial Disk Displacement with Reduction
Definition: Change in the disk-condyle structural relation during mandibular translation with mouth opening and closing Etiology: Articular surface irregularity Disk-articular surface adherence Synovial fluid degradation Myofascial imbalances around the joint Increased elongation of diskal ligaments and posterior attachment

8 5 Progressive Stages Stage I Disk Displacement
Temporal mandibular ligament becomes elongated Disk drops medially - subluxes which reduces upon closure Ligament brings the disk back into place upon closure Each stages has a different associated clicking from when it slips

9 Symptoms of Stage 1: Very little pain
Inconsistent click occurs early in opening phase. Subluxation on opening and a lateral reduction in closing


11 Stage II Disk Displacement
TM ligament continues to elongate, disk moves more medial and anterior on mandibular head. Reduction on mouth opening, subluxation on closing Clicking: Early on opening and Late on closing

12 Figure 11. Partial anterior disk displacement.
Figure 11.  Partial anterior disk displacement. Sagittal MR image (2,800/15) of TMJ with the jaw closed shows the posterior band (arrow), which is at the 10 o'clock position. Sommer O J et al. Radiographics 2003;23:e14-e14 ©2003 by Radiological Society of North America

13 Symptoms of 2: Reciprocal click early on opening and late on closing Pain Signs: C curve upon mouth opening: goes back and lateral towards dysfunctional side.

14 Open Lock: Potential to occur from Stage II on
Signs: two opening clicks Two closing clicks Condyle can be prevented from slipping back in place if disk lies too posterior to the condyle

15 Stage III Significant TM ligament elongation overstretching occurs causing posterior ligament elongation, disk shape distorted. Condyle loses vertical height Capsule becomes shortened

16 Symptoms 3: click is more consistent Click occurs later on opening and earlier on closing
Most painful stage Signs: C curve Limited range of mouth opening to 25 to 30 mm, just below functional: 35mm is limit.

17 Closed Lock condition Closed lock: sudden limitation of jaw opening
Disk is permanently lodged anteriorly and interferes with normal rotation and translation of the joint Hard end-feel

18 Stage IV: Rotational Displacement
Symptoms: Pain Signs: Clicking rare or single opening click

19 Stage V: Signs: radiographic degenerative changes on condylar head, articular eminences (less often) Evidence of remodeling (sclerosis) and osteophytes Marked deformity of disk, thickening of disk and shape change

20 C. Anteromedial Disk Displacement with Intermittent Locking
Disk is displaced Shape is deformed over time from biconcave to biconvex Symptoms: intermittent locking in the am or after a period of clenching or chewing on involved side, brucsizum (teeth night)

21 D. Anteromedial Disk Displacement without Reduction
Definition: change of the disk-condyle structural relationship which is maintained during mandibular translation Disk remains displaced with a closed-lock occurring Lose: contact with condyle, disk and articular eminence of condyle which prevents posterior translation from occurring Signs: Deviation of mandible towards involved side Marked limitation of lateral deviation to contralateral side

22 Internal Derangement of the Disk
Deviation in Form Frictional Disk Incoordination: Definition: intra-articular disk adheres to the eminence Onset: Etiology: loss of lubrication, roughness in the articular surface Signs: loss of translatory glide opening click Symptoms: minimal discomfort with the click

23 Deviation in Form Articular Surface Defects
Definition: articulating surface has a roughed area or a change in the articular cartilage which doesn’t allow smooth rolling or gliding during opening and closing of the mouth Etiology: Signs: reciprocal click during opening and closing of the mouth Lateral deviation on opening

24 Deviation in Form Disk Thinning and perforation
Etiology: application of excessive pressure on the TMJ, overloading with teeth together Symptoms: variable joint tenderness, muscle pain Signs: grating sound, crepitus during opening and closing DX: made with medical imaging studies

25 Hypermobility and Dislocation
-Hyper: at risk for a locked open mouth. Subluxation Dislocation Hypomobility: capsular vs adhesive disk

26 A. Joint Subluxation Mandibular Head Subluxation
1. Biomechanical considerations 2. Arthrokinematic dysfunctions a. max. rotation occurs before translation begins b. maximum translation occurs and a shift of condyle and disk as a unit occurs

27 Subluxation versus Reduction of Displaced Disk
Subluxed Disk: Occurs only on wide opening Does not occur with protrusion or lateral deviation Pain is not always present Reduction Disk: Occurs on opening for stage I, closing (except in stage 1) and protrusion and contra-lateral lateral deviation

28 B. Joint Dislocation Condyle moves outside of the physiological boundaries of the joint Etiology: yawning (to wide), singing, sleeping with head on forearm, excessive tooth abrasion, malocclusion, over-closure and trauma Sx: open lock position mouth is unable to close, locked open Rx: manipulation, splint

29 Ankylosis: stuck Fusion of TM joint Symptoms: Signs: Tx Fibrosis Bony
Opposite side may become painful Signs: Decreased ROM C curve on mouth opening Tx How to f(x) with it.

30 Adhesive Disk Hypomobility
Definition: intra-articular formation of adhesions within the disk Usually in the superior joint cavity, causes loss of condylar translation Condylar displacement of disk may occur Distortion of disk on mouth opening

31 Adhesive Hypomobile Etiology:
Trauma: mild may only cause frictional disk incoordination or articular surface defect Major: intra-articular bleeding, swelling, fibrosis can result Restricts ROM May progress to joint degeneration

32 Sx: Click – Signs: Early is within 10 mm of opening,
Intermediate between 10 and 20 mm, Late after 30 mm of opening. C/o a locking sensation Signs: mandible deviates away from the dysfunctional side during mouth opening S-curve: jaw goes to both sides correcting and over-correcting.

33 Inflammatory Conditions
Synovitis and Capsulitis Retrodiscitis Arthritic Conditions Osteoarthritis Rheumatoid Arthritis Other Arthritic Conditions

34 Capsulitis SX: continuous deep constant pain
Originates in joint area Pain with mouth opening Signs: palpable pain with compression to the lateral pole of condyle Limitation of mouth opening Myospasms secondary to pain Tissue stretch end feel or empty end feel Decreased protrusion , may deviate to side of dysfunction Increase pain with passive stretch

35 Retrodiscitis Anterior displacement of disk, condyle presses on posterior tissue causing an inflammatory reaction Hx: trauma, chronic bruxing SX: constant, dull, aching pain, aggravated by joint movement -closure puts it back into place. Signs: empty end feel, acute malocclusion, decrease protrusion, pain with compression

36 Non-Articular Conditions
Muscle Spasms Masseter Temporalis Lateral Pterygoid Medial Pterygoid Myositis Myofascial Pain Syndrome Muscle Contracture

37 Practice Pattern 4E: Muscle Spasms
Causes: trauma, occlusal imbalance, changes in vertical dimensions between teeth, immobilization, prolonged dental procedures, chronic teeth clenching, disease

38 Three Categories of Muscle Spasms
Protective Co-contraction: muscle guarding Causes: Chronic inflammatory process, emotional stress, habit, muscle tendon injury Sx: pain with active jaw movement Signs: pain with resisted movements, pain at end range with passive movements, empty end feel or muscle spasm end feel chronic inflammatory processes Pain - afferent input from the joint receptors during joint dysfunction Emotional stress -sympathetic nervous system response Habit - clenching teeth Muscle tendon injury

39 2. Local Muscle Spasm Protective muscle co-contraction,
Leads to prolonged isometric contraction of muscle. Leads to decrease in blood flow, Inflammatory response, increase pain, increase muscle guarding, more pain History: blow to face, dislocation of jaw SX: periarticular, pain with chewing Signs: pain with AROM mouth opening, PROM, Resisted muscle testing, dec. in mouth opening pain with overpressure during mouth opening

40 3. Specific Muscles, Trigger Points
1. Temporalis a. HX: headaches in temporal region b. SX: headaches, visual disturbances, pressure behind eye, increase eye fatigue, difficulty with night vision

41 c. Signs: Restriction of mouth opening
Deviation of mouth toward affected side Pain with palpation Pain with resisted motions of elevation but not protrusion Muscle trigger point with referred pain pattern S curve on mouth opening Decrease in freeway space (mouth opening at rest) Abnormal protrusion of condyle on contralateral side during lateral deviation Intermittent tooth ache

42 2. Masseter c. Signs: restriction of mouth opening deviation of mouth toward affected side pain with palpation referred pain pattern upon compression pain with resisted motions of elevation but not protrusion a. HX: b. SX: pain to lower jaw, molar teeth and related gums, pain with chewing or with increased jaw activity unilateral tinnitus Bruxism: jaw clenching

43 3. Medial Pterygoid c. Signs: Ache inside the mouth a. HX: b. SX:
Restriction in mandibular opening No deviation of jaw Rarely the primary muscle, Usually a 2ndary area Ache inside the mouth a. HX: b. SX: Pain with wide mouth opening pain with clenching teeth painful swallowing

44 4. Lateral Pterygoid: “TMJ” dysfunction b. Signs: a. SX:
Pain in region of TMJ and maxilla Clicking sounds may occur, so need to be careful to d(x) b. Signs: Pain with compression on same side as dysfunction Slight restriction of mouth opening, occlusal abnormality ROM: for Lateral deviation away from the side of dysfunction is decreased ROM decreased

45 Oncological A. Rare occurrences, but can get a metastatic adenocarcinoma in the TMJ region B. Signs: unrelenting pain of unexplained origin, neurological deficits, nausea, balance disorders, visual changes, cranial nerve disorders C. Refer if suspect

Goals are based on physical exam Treat pain: Address biomechanical asymmetries Postural education: like forward head Strengthen supporting structures necessary to balance head, maintain new position Stress reduction

47 Occlusional appliance:
Splint: removable, hard, acrylic “bite guard” a. muscle relaxation b. anterior (orthopedic) repositioning appliance c. anterior bite plate d. posterior bite plate

48 Medical Treatment: Arthroscopic surgery done for disk repositioning
Decrease adhesions Take out osteophytes

49 Other References: 1. Bourbon BM: “Craniomandibular Examination and Treatment” in Saunders Manual of Physical Therapy Practice, WB Saunders Co. Philadelphia, 1995 2. Richardson JK and Iglarsh ZA. Clinical Orthopaedic Physical Therapy, W.B. Saunders Co., Philadelphia, 1994. 3. Magee D. Orthopedic Physical Assessment, 4th ed

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