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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 2

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 3

4 Figure 5. a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position. Sommer O J et al. Radiographics 2003;23:e14-e14 ©2003 by Radiological Society of North America 4

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

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 6

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 7

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 8

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

10 10

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 11

12 Figure 11. Partial anterior disk displacement. Sommer O J et al. Radiographics 2003;23:e14-e14 ©2003 by Radiological Society of North America 12

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. 13

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 14

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

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. 16

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 17

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

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 19

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 clenching @ night) 20

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 21

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 22

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 23

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 24

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

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 26

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 27

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 28

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

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 30

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 31

32 Sx: Click – ◦ 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. 32

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

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 34

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 35

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

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

38 Three Categories of Muscle Spasms 1. 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 38

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 39

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 40

41 c. Signs: ◦ 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 Restriction of mouth opening Deviation of mouth toward affected side Pain with palpation Pain with resisted motions of elevation but not protrusion 41

42 2. Masseter 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 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 42

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

44 4. Lateral Pterygoid: “TMJ” dysfunction 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 44

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 45

46 PT TREATMENT OF TMJ DYSFUNCTIONS Goals are based on physical exam 1. Treat pain: 2. Address biomechanical asymmetries 3. Postural education: like forward head 4. Strengthen supporting structures necessary to balance head, maintain new position 5. Stress reduction 46

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 47

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

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, 4 th ed. 2002 49

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