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Diseases of the temporomandibular joint

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1 Diseases of the temporomandibular joint

2 Surgical anatomy The temporomandibular joint consists of glenoid fossa on the skull base, the condyle, the articular disk separating the fossa and the tubercle, a capsule, and ligaments connected to the capsule. Both the glenoid fossa and the condyle are covered by hard, fibrotic, cartilaginous tissue, which is the thickest deep in the fossa. The condyle of the mandible is cylindrical, it becomes narrower in the posterior direction, its greatest diameter, in the mediolateral direction is about 2 cm. With a narrow neck, it passes through into the condylar process. It was earlier believed that the cartilaginous surface covering the condyle behaved as the epiphyseal plate, and that the growth centre of the mandible was situated here. It has recently been proved, however, that the growth of the capitulum is a function of the functional matrix surrouning it. This functional matrix involves the joint function of the articulation, the masticatory muscles and the soft tissues. If some restraining effect is experienced anywhere in the matrix, the condyle and also the whole of the mandible undergo a retardation of growth.

3 Surgical anatomy From a side view the articular disc covering the mandibular condyle is like a biconcave cap. The joint space is divided into an upper and a lower compartment. The disk consists of dense, fibrotic, cartilaginous tissue. The capsule of the articulation joint is supported by temporomandibular, stylomandibular and sphenomandibular ligaments. The last has an important role as a surgical indicator, for the maxillary artery and the auriculotemporal nerve run between the mandibular neck and the sphenomandibular ligament. The blood supply of the condyle is ensured from the superficial temporal artery and the branches of the maxillar artery

4 Diagnostic imaging procedures relating to the TMJ
Many types of diseases can affect the TMJ, but the location and structure of the normal TMJ mean that it is extremely difficult to examine it with some imaging system. At present however numerous devices and methods are available that can help to get the diagnosis.

5 Diagnostic imaging procedures relating to TMJ
Conventional X-ray techniques Panoramic X-ray techniques arthrography Computer tomographic imaging (CT) 2-3D Magnetic resonance imaging (MRI) arthroscopy

6 Functions of TMJ The TMJ is the only paired joint in the body that performs its functions in a syncronised and coordinated way. It functions are influenced by three fundamental factors Anatomic structure of the TMJ Neuromuscular mechanism Dental occlusion

7 The functions of TMJ As a result of the hinge movement, the mouth opens about mm, in consequence of combination of rotating and gliding movements, the distance rises to mm. The rotation is produced by the contraction of the anterior belly of the digastric muscle and the geniohyoid muscle Sliding in the anterior direction is mainly due to the lateral pterygoid muscle Sliding to posterior direction depends on the functions of the deep fibers of the masseteric muscle and the posterior fibres of the temporal muscle Parts are played in the closure by the paravertebral muscles and by the stylohyoid, geniohyoid and infrahyoid muscles. The most important roles are played by the masseteric muscle and the medial pterygoid and temporal muscles.

8 Temporomandibular disorders Keith classification
Congenital and acquired growth disturbances Infections Ankylosis Traumatic laesions Dislocation (luxation) Internal derangement Degenerative diseases Tumors

9 Congenital growth disturbances
Unilateral disorders Hemifacial microsomia Hemifacial microsomia is unilateral hypoplasia or aplasia of the TMJ, it is an asymmetric, progressive deficiency which relates to both soft tissues and the bony sceleton of the scull. The developmntal problem of the first and second branchial arches can cause this disease. It is classified in three groups Type I. :”minimanbible” All parts of the mandible are present and the arch is normal, but they are small Type II.: Small and anomalously arched ramus, and hypoplastic, anteriorly and medially situated condyle Type III.: total unilateral absence of the condyle and ramus

10 Congenital grows disturbances
Bilateral developmental anomalies of the first and second branchial arch Treacher Collins syndrome (mandibulofacial dysostosis) It is characterized by a bilateral hypoplastic TMJ a short ramus and a decreased face height. This syndrome is a dominantly inherited abnormality. Its rate of occurance is 1: Clinical appearance is always bilateral. Retractions may be observes on eyelids, the lower eyelashes may be missing. The external ear is hypoplastic, hearing disturbance exists.

11 Acquired TMJ deformities
Condylar hyperplasia It is the most frequent postnatal abnormality of TMJ . It appears in the years before puberty. It is assumed that the cause of the changes lies in the more active metabolism of the condyle Two different growth tendencies may be distinguished Vertical The mandible grows mainly in vertical direction, which results vertically long ramus and body. Rotational Besides the enlarged condyle and vertically long ramus, the convex enlargement of the body leads to a crossbite and mouth opening deviation. The enhanced metabolism may be proved by bone scintigraphic examination.

12 Infections Before the advent of antibiotics, infectious diseases of the TMJ were much common than today. Description from the 19th and 20th centuries revealed that infections of the ear and teeth often spread to the joint. The primary causes of TMJ were infectious diseases of childhood (scarlet fever, chickenpox, diphteria, etc.) Symptoms: Intense pain The most comfortable position for the patient is the opened mouth Oedema, erythema above the joint, than fluctuation The cronic state was indicated by a fistula in the region of TMJ.

13 Ankylosis  There is a lot of expression, which means the disability of the movement of TMJ trismus, pseudoankylosis, ankylosis.

14 Trismus: This is an anomaly based on muscle spasm.
Extracapsular process, the TMJ itself is not effected. Classic examples of the lesion are the complications that arise in the course of conduction anaesthetization. (infection, bleeding or nerve damage) Pseudoankylosis: Intraarticular cause: fibrosus ankylosis. Extraarticular cause: Include the hyperplasia of the coronoid process or its unification with the maxillary tuber or with the zygomatic bone, or a fractured zygomatic arch. It may occur as a chronic scar contracture of the temporal muscle as a consequence of irradiation or surgery. Ankylosis: This is a bony unification of the condyle and the glenoid fossa.

15 Ankylosis Etiology: Trauma Rheumatoid arthritis Infection Tumors
In childhood there are a lot of vessels in the joint, which runs between the condyle and the capsule. In the event of trauma haemarthrosis will develop, which undergoes ossification. In adulthood 51% of the cases of polyarticular rheumatoid arthritis affect the TMJ. ( usually only one) In childhood, the most serious consequece of ankylosis caused by RA is the facial deformity due to the damage to the growth centre. The development of the lower third of the face is retarded and a „birdface” results.

16 Ankylosis Infections: This is now rare as a cause.
Tumors: Are similary rarely observed in the TMJ

17 Diagnosis History Panoramic X-ray 3D CT imaging

18 Treatment In childhood there are 4 groups in ankilosys and the treatment vaies group to group, 1.On the X ray the articular gap is narrowed, but it can be followed. 2.The lateral parts of the articular surface there are much more synostosis but on the medial deeper parts of the TMJ the cartilaginous surfaces are preserved and the disk may be distinguished 3. There is a bridge-like synostosis between zygomatic arch and ramus of the mandible. The medial part of the capitulum is intact and able to function. 4. The extent of synostosis is such that the TMJ can no longer be recognized.

19 Treatment The first step in treatment is surgery. The TMJ is usually exposed from preauricular incision. In cases belonging to the first two groups the TMJ can be easily recognised after exposure. After closure and postoperative period the second step is functional treatment.

20 Treatment In adulthood
To avoid reossification some „interposit” is recommended between the reformed articular fossa and condyle. This may be the temporal muscle, cartilage or alloplastic material.

21 Injuries Dislocation takes place most often in the anterior direction, the condyle becomes positioned in front of the articular tubercule. Subluxation- The dislocatio is not complete, the condyle can return to the glenoid fossa Recurrant luxation - The luxation or subluxation occurs on a number of occasions but there is no psychological factor inducting compulsive movement. Habitual luxation is coused by compulsive movements. The terms luxation, distorsion and dislocation are used when the articular surfaces are totally separated from one another and the joint is fixed in this extraarticular position. It may be induced by an external ( hit, extraction) or an internal action (huge yawn, vomiting, singing, dental procedure). The direct cause of spontaneous luxation is sudden disturbance of the coordination of the muscles movement.

22 Symptoms The patient cannot close his or her mouth
The mandible is elastically fixated The articular fossa is empty Moderate pain in the joint

23 Treatment Acute, chronically persistent, recurrent and habitual luxation demand different modes of treatment Acute: Reposition- The earlier the repositioning is attempted the more easily succedes. The thumbs are wrapped in gauze and placed on the occlusal surface of the mndibular molars or alveolar ridges. By pressing firmly on the molars and elevating anteriorly with simultaneous backward pressure, the condyle is relocated. Chronically persisting luxation: Reposition under general anaesthesia, when the reposition is unsuccessful, condylectomy may be considered Recurrent: The reposition is generally easy but it is difficult to avoid repetition of the luxation. Conservative or surgical treatment. Habitual: It is difficult to know how to alter psychological component that includes the compulsive movement.

24 Internal derangement  The internal derangement means intracapsular damage of the TMJ which primary arises from the incorrect movement of the articular disk together with the secondary changes of movement. The disease does not belong to developmental anomalies or to other diseases of the TMJ.

25 Internal derangement The healthy articular disc allows the appropriate distance between the condyle and the glenoid fossa Firstly the articular disc displaces, the posterior fibers of the disc becomes loosened, the condyle will be posteriorly positioned

26 Internal derangement A further change occure if the disc streches and becomes thinner and the articular gap is reduced progressively in both posterior and anterior direction The following step is the rupture of the disc, so the glenoid fossa and the condyle come into direct contact The condyle slowly becomes pointed in the anterior and posterior direction and finally degenerative changes occur in the bone

27 Internal derangement Symptoms
pain, deviation, repeated clicking when the mouth is opened and reciprocal clicking when closed Treatment is primary conservative and only rarely surgical Medication: NSAID, night bite guard (bite raising appliances)

28 Degenerative diseases
Osteoarthrosis (arthrosis deformans, osteoarthritis). It is a non-inflammatory degenerative diseases which mainly affects the articular surfaces but it also induces reconstruction of and changes in the bone beneath the articular surface. Symptoms: Pain, crepitation, restriction of articular movement  Rheumatoid arthritis Autoimmune disease of the small periferial joints. In women it is three times common than in men. In 10-15% of the cases involve a progressive variant with articular destruction and deformities. The inflammation of the synovial membrane is carasteristic. The inflammatoric process damages the joint and the scar tissue impedes the movements. Symptoms: Intermittent pain, swelling and progressive restriction of the articular movement. Typical that the small joints of the hand and foot become involve first.

29 Other degenerative diseases
Gout This is a metabolic disease, uric acid crystals are deposited in and around the joints and these causes inflammatory symptoms. Above the joint the skin is red and swollen and in particular movement gives rise to pain. Other degenerative diseases Spondylitis accompanied by ankylosis It differs from RA that here primarily the ligaments around the joint undergo calcification and osification. Psoriatic arthritis: symmetric polyarthritis and negative rheumatoid factors Posttraumal arthritis: Arthritis may develop as a consequence of trauma Condyle resorption: after bilateral condyle fracture or as a consequence of otitis media

30 Degenerative diseases
Treatment Conservative -pain killers -normalisation of the occlusion -interocclusal plates -sedatives -steroid intraarticulary Surgical - condylectomy - arthroplasty

31 Tumors of TMJ  The tumors of TMJ are very rare. These could develop from some parts of the joint or may spread from the environment of the joint. Benign tumors The condyle may be enlarged for many reasons, e.g.: acromegalia, fibrosus dysplasia, condylar hypertrophia, osteoma, osteochondroma, chondroma stb. Common typical symptoms: Slow restriction of the movement of the joint Painless swelling in the region

32 Metastases Primer tumor could be in prostata, breast, kidney,
malignant melanoma, lung, pancreas etc.

33 Thank you for your attention!

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