1. Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis, arthrosis temporomandibular joint (TMJ): classification, clinical course, diagnosis, treatment, complications and prevention. TMJ syndrome of pain disfunction. Surgical TMJ arthroscopy.

3. CLINICAL SYMPTOMS ACUTE SINUSITIS < 3 weeks SUBACUTE SINUSITIS 3 weeks-3 months CHRONIC SINUSITIS > 3 months

4. SYMPTOMS Bloked nose Headache Fever Yellow or green-coloured mucus from the nose Swelling of the face Aching teeth in the upper jaw Loss of the senses of smell and taste Persistent cough Generally feeling unwell

5. MAXILLARY SINUSITIS FROM DENTAL ORIGIN 1.Periapical abscess 2.Periodontal diseases 3.Infected dental cyst 4.Dental material in antrum 5.Oroantral communication

6. 1.Periapical abscess Acute sinusitis Anaerobic organisms 2.Periodontal diseases Lane & O’Neal Chronic sinusitis 5 years irrigation + antibiotics examination communication with the maxillary sinus via a periodontal pocket

7. 3.Infected dental cyst Periapical cyst Most common of all cysts of the oral region Epithelium rest of Malassez The cyst enlarges in to the maxillary sinus

8. 4.Dental material in antrum 1.Displacement of root extraction third molar > second molar > canine Pa or occlusal film loss of lamina dura 2.Implant 3.Root canal overfilling

9. CASE REPORTS

11. 1.Antral puncture and sinus irrigation

12. 2.Intranasal antrostomy or Nasoantral Window

13. 3.Caldwell – luc operation

15. Mandibular condyle (head) Glenoid fossa Articular tubercle (eminence)

16. Lateral pterygoid muscle raphe Lower head of lateral pterygoid muscle Anterior band of articular disc Mandibular condyle (head) Posterior band of articular disc Posterior disc attachment

17. Mandibular condyle (head ) Articular disc

18. MRI and autopsy sections: upper row oblique sagittal MRI, asymptomatic volunteer: left lateral, middle medial, right opened mouth

19. lateral sectionscentral sectionsopen-mouth Partial anterior disc displacement at baseline

20. Complete anterior disc displacement Open- mouth MRI medial section Autopsy

21. Lateral disc displacement and normal bone

22. Medial disc displacement Oblique coronal MRI coronal MRI

23. Posterior disc displacement

24. Definition  Non-inflammatory focal degenerative disorder of synovial joints, primarily affecting articular cartilage and sub-condylar bone; initiated by deterioration of articular soft-tissue cover and exposure of bone. Clinical Features  Crepitation sounds from joint(s)  Restricted or normal mouth opening capacity  Pain or no pain from joint areas and/or of mastication muscles  Occasionally, joints may show inflammatory signs  Women more frequent than men

25. anteriorly displaced and deformed, degenerated disc and irregular cortical outline with osteophytosis and sclerosis of condyle.

26. Advanced osteoarthritis and anterior disc displacement, with joint effusion

27. Imaging Features Abnormal signal on T2-weighted image from condyle marrow: increased signal indicates marrow edema; reduced signal indicates marrow sclerosis or fibrosis Combination of marrow edema signal and marrow sclerosis signal in condyle most reliable sign for histologic diagnosis of osteonecrosis Marrow sclerosis signal may indicate advanced osteoarthritis without osteonecrosis, or osteonecrosis

28. Definition  Inflammation of synovial membrane characterized by edema, cellular accumulation, and synovial proliferation (villous formation). Clinical Features  Swelling of joint area, not frequently seen in TMJ  Pain (in active disease) from joints  Restricted mouth opening capacity  Morning stiffness, in particular stiff neck  Dental occlusion problems; “my bite doesn’t fit”  Crepitation due to secondary osteoarthritis

29. After 1 year

30. Rheumatoid arthritis. A MRI shows completely destroyed disc, replaced by fibrous or vascular pannus and cortical punched-out erosion (arrow) with sclerosis in condyle.

31. Psoriatic arthropathy. Oblique coronal and oblique sagittal CT images show punched-out erosion in lateral part of condyle (arrow). Psoriatic arthropathy. MRI shows contrast enhancement within bone erosion and in joint space, consistent with thickened synovium/pannus formation. Openmouth MRI shows reduced condylar translation but normally located disc (and normal bone in this section)

32. Inflammatory arthritis

33. Definition Fibrous or bony union between joint components.

34. Definition Abnormal growth of mandibular condyle; overgrowth, undergrowth, or bifid appearance.

35. Normal TMJ Condylar Hypoplasia Condylar hypoplasia and facial asymmetry

36. Bifid condyle.

37. Calcium Pyrophosphate Dehydrate Crystal Deposition Disease (Pseudogout)

38. Synovial Chondromatosis  Benign tumor characterized by cartilaginous metaplasia of synovial membrane, usually in knee, producing small nodules of cartilage, which essentially separate from membrane to become loose bodies that may ossify.

39.  Different pathologies affecting the masticatory muscles, the temporomandibular joint (TMJ), and related structures  Affects more than 25% of the population  90% of those seeking treatment are women

40.  Facial pains/Muscle spasms  Pain/tenderness in the muscles of mastication and joint  Joint sounds (popping, clicking)  Limited jaw motion  Jaw locking open or closed  Headaches  Teeth grinding  Abnormal swallowing  Uncomfortable “off” bite  Inability to comfortably open/close mouth  Dizziness/vertigo  Ringing in the ears  Visual disturbances  Insomnia  Tingling in hands/fingers  Deviation of jaw to one side

41.  Osseous Anatomy  The articulation between the condyles of the mandible and the temporal bone, which is part of the cranium.  The articular surface of the condyle is convex and the articular eminence of the temporal bone is concave.

42.  Working together:  Dentists  Orthodontists  Psychologists  Physical Therapists  Ear, Nose, Throat Doctor  Physicians  Alternative Medicine

43.  MRI  X-Ray  Dental examination for bite alignment

44.  Physical Therapy is an important aspect in the treatment for TMD to:  Relieve musculoskeletal pain  Decrease inflammation  Restore normal joint/muscular movements for oral motor function  Correct poor posture

45.  History  Posture  Watch, feel, listen to jaw with AROM  Opening between 40-50mm  Protrusion/retraction between 8-10mm  Lateral deviation while opening (S or C curve)  Lateral excursion 8-10mm  Ligamentous Laxity testing  Transverse Ligament  Alar Ligament  Cervical ROM testing  Palpate joints/muscles for tenderness

46.  Therapeutic Exercises  Manual Therapy  Modalities  Electromyographic (EMG) Biofeedback  Dental Splint

47.  Improve muscular coordination  Increase muscular strength  Postural exercises  Active ROM exercises  Muscles of mastication  Cervical spine muscles  General mobility

48.  Make a “clicking” sound with the tongue on the roof of the mouth. This slightly opens the jaw with the tongue on the palate behind the front teeth, which is the resting position of the jaw and the first portion of relaxation exercises.  Place tip of tongue on palate behind teeth and draw small circles.  Place tip of tongue on hard palate and blow air out, rolling the tongue, or making a “r r r r” sound.

49.  Begin with proper resting position of the jaw. Teach the patient control while elevating and depressing the mandible throughout the first half of the ROM.  Keeping the tongue on the roof of the mouth, the patient opens the mouth while trying to keep the chin in midline. Use a mirror for visual reinforcement.  If the jaw deviates to one side, teach the patient to practice lateral deviation to the opposite side without creating pain or excessive motion.

50.  Long Axis Distraction:  Sitting/Supine  PT positioned opposite of affected side  Use hand opposite of affected jt. side  Thumb in mouth on last molar  Apply gentle downward pressure with thumb  Hold for ~30 seconds 2- 3x/session  Bilaterally  Anterior Glide  Same hand placement  Slightly distract using DIP of thumb while gliding anteriorly  Oscillate for 30 seconds

51.  Lateral Glide  Thumb on tongue side of last molar  Use whole hand to oscillate laterally  Medial Glide  Stand on affected side  Thumb on lateral side of last molar  Glide medially

52.  Avoid:  Large bites  Excessive chewing  Removing food from teeth with tongue  Gum chewing  Chewy foods: bagels, sandwiches, steak, ice, crunchy fruits/vegetables, caramel, nuts etc.  Relaxation techniques to reduce stress/muscle tension  Maintain good posture

54.  5-10 % dx w/TMJ Dysfunction fail to have relief of medical tx, and require surgery  Antiinflammatories, soft diet, hot compresses, muscle relaxants  >2 weeks: intraoral occlusion splints, med tx  Recurrent or chronic: permanent dental correction

55.  Patient Factors  Outpatient  H& P, Blood chemistries, CBC, PT, PTT, U/A, serum HCG, Chest x-ray or ECG as appropriate  Room Set-up  X-rays in room

56.  Position during procedure  Supine w/head donut pillow, tuck arms to side  Supplies and equipment  Arm sleds, headring pillow  Special considerations: high risk areas  Elbows—ulnar nerves  Prep  Shave preauricular area  Cotton to ears to prevent pooling of povidone-iodine & caution w/eyes; entire facial area prepped from hairline, down to shoulder, and laterally to include mouth and chin

57.  Special considerations  Nasal intubation  Prophylactic antibiotics & steriods  State/Describe incision  Small stab incision w/# 11 before trocar is introduced at superior joint space

58.  General: basic pack drape and split head sheet, gowns & gloves, towels, basin set, prep set, sterile adhesive wound drape, irrigation pouch, skin marker, raytex,  Specific  Suture & Blades (# 11)  Medications on field (name & purpose)  Catheters & Drains: n/a  Drapes: head turban for initial drape; pad pt forehead with a folded towel; plastic adhesive wound drape to cover ET tube and mouth; split sheet and large sheet for body drape, (laser: 4 wet towels around pt’s face; moistened cotton in external auditory canals, irrigation collection pouch at base of ear and TMJ)

59.  2 60 mL syringes  4 10 mL syringes  1 1-mL syringe  Needles: 18 g, 21 g, 25 g  Skin stapler  Eye pads  Sterile water and saline  1000 mL Lactated Ringers for irrigation  30 in extension tubing  Stopcock

60.  General: suction, Lactated Ringer’s IV bag for irrigation, marking pen  Specific  TMJ instrument set  0 degree arthroscope  30-degree arthroscope  70-degree arthroscope  Cannulas  Sharp & dull obturators  Light cord, camera & cord, small joint rotary shaver

61.  General: suction system  Specific  Monitor/light source/camera tower, shaver control unit, IV pole for irrigant  Fluid infusion system  Bipolar ESU  Holmium laser

62.  Irrigation solution is injected into the joint space to distend the capsule  LR solution is preloaded in syringe w/needle attached.  After small stab incision is placed, surgeon inserts a sheath w/sharp obturator into superior joint space. After space is entered, the sharp is replaced with a dull obturator to further direct the sheath into the joint without damaging the intraarticular tissue or adjacent neurovascular structures.  #11 blade with # 7 handle will be ready  Trocar/cannula is preassembled. Expect trocor to be returned. Be prepared to assist with connections of video/light cord connections.

63.  Irrigation is infused into the joint  LR solution is connected to the cannua via extension tubing  Joint is examined  Prepare to operate remote control for still photos  If functional surgery is needed, a second stab wound is made  Pass skin knife. Prepare additional equipment (probe, shaver, grasper)  Final visual inspection is performed  Additional photos may be taken

64.  Cannuale are removed and excess fluid removed  Prepare for closure; count  Wound is closed and dressing placed  Pass suture; prepare dressings, reorganize equipment & supplies if procedure is bilateral  Steps may be repeated contralaterally  Repeat steps

65. Thank you