Temporomandibular Ioint Disorders

Temporomandibular Joint Disorders Important Notes

1. Classification Of TMJ Disorders

• Disorders due to extrinsic factors
  • Masticatory muscle disorders.
    • MPDS
    • Myositis.
  • Problems due to trauma
    • Traumatic arthritis
    • Fracture
    • Internal disc derangement
    • Tendonitis
• Disorders due to intrinsic factors
  • Trauma
    • Dislocation
    • Fracture.
• Internal disc displacement
  • Anterior disc displacement with reduction.
  • Anterior disc displacement without reduction.
• Arthritis.
  • Osteoarthritis
  • Rheumatoid arthitis
  • Juvenile arthitis
  • Infantile arthritis.
• Developmental defects.
  • Agenesis
  • Hypoplasia
  • Hyperplasia
• Ankylosis
• Neoplasm
  • Benign
  • Malignant

Read And Learn More: Oral and Maxillofacial Surgery Question and Answers

2. Classification Of Ankylosis:

• False or true analysis
• Extra articular or intra articular
• Fibrous or bony
• Unilateral or bilateral
• Partial or complete.

3. Treatment Of Ankylosis

4. Causes Of Trismus:

• Orofacial infection
• Trauma
• Inflammation
• Myositis
• Tetany
• Tetanus
• Neurological disorders
• Drug-induced
• Extra articular fibrosis
• Mechanical blockage

5. Eminectomy:

• Eminectomy involves the excision of the articular eminence

6. Hyperplasia Of condyle:

• The patient exhibits a unilateral, slowly progressive elongation of the face
• Deviation of the chin occurs away from the affected side

7. Hypoplasia Of condyle:

• Facial asymmetry occurs
• Limitation of lateral excursions on one side
• Exaggeration of the antegonial notch

8. Conditions Where The Jaw Deviates To The Same Side:

• Ankylosis of TMJ
• Subcondylar fractures
• Hypoplasia of condyle

9. Kaban’s Protocol:

• Early surgical intervention Aggressive resection
• Ipsilateral colectomy
• Contralateral colectomy
• The lining of the glenoid fossa with temporalis fascia
• Reconstruction of ramus with osteochondral graft
• Early mobilization
• Regular follow up

10. Ankylosis Features:

• Unilateral
  • Face is asymmetry
  • Fullness occurs on the affected side of the mandible
  • Flattening on the unaffected side occurs
• Bilateral:
  • Gives a typical bird-face appearance

11. Interposition Arthroplasty:

Involves the creation of a gap and insertion of a barrier between the cut bony surfaces

• Interposition Arthroplasty Advantages:
  • Minimizes the risk of recurrence
  • Maintains the vertical height of the ramus.

Temporomandibular Joint Disorders Long Essays

Question 1. Classify TMJ disorders. Explain in detail about anterior dislocation & its management.
Or
Describe the etiology and pathogenesis of TMJ ankylosis. Describe different surgical procedures for TMJ
Or
Describe Subluxation.
Answer:

Classification:

1. Disorders Due To Extrinsic Factors:

• Masticatory Muscle Disorders:
  • MPDS
  • Myositis
• Problems Due To Trauma:
  • Traumatic arthritis
  • Fracture
  • Internal disc derangement
  • Tendonitis

2. Disorders Due To Intrinsic Factors:

• Trauma:
  • Dislocation
  • Fracture
• Internal Disc Displacement:
  • Anterior disc displacement with reduction
  • Anterior disc displacement without reduction
• Arthritis:
  • Osteoarthritis
  • Rheumatoid arthritis
  • Juvenile arthritis
  • Infantile arthritis
• Developmental Defects:
  • Agenesis
  • Hypoplasia
  • Hyperplasia
• Ankylosis:
• Neoplasm:
  • Benign
  • Malignant

Anterior Dislocation:

Causes Of Anterior Dislocation:

1. Extrinsic Causes:
   • Blow on the chin when the mouth is open
   • Injudicious use of mouth gag
   • Post-traumatic
2. Intrinsic Causes:
   • Excessive yawning
   • Vomiting
   • Singing loudly
   • Laughing loudly
   • Opening mouth too wide

Features Of Anterior Dislocation:

1. Unilateral:
   • Difficulty in mastication & speech
   • Profuse drooling of saliva
   • Deviation of the chin over the contralateral side
   • The affected condyle is not palpable
   • Definite depression in front of the tragus
2. Bilateral:
   • Pain
   • Inability to close mouth
   • Tense masticatory muscles
   • Difficulty in speech
   • Excessive salivation
   • Protruding chin
   • Gagging of molars
   • Anterior open bite
   • Difficulty in swallowing
   • Hollowness in particular regions

Management Cf Anterior Dislocation:

• Reassure the patient
• Sedative drugs
• Pressure & massage the area
• Manipulation

• Operator grasps the patient’s mandible
• The thumb is placed over the occlusal surfaces of the lower molars
• Fingertips are placed below the chin
• Downward pressure is placed over posteriors
• This overcomes spasms of muscles
• Backward pressure is applied which pushes the entire mandible posteriorly
• Immobilization is done

Manipulation Of Condyle:

• Capsule Tightening Procedure:
  • Capsulorrhaphy:
    • Shortening of the capsule by removing a section & suturing
    • Placement of vertical incision & tightening it
    • Reinforcement of capsule by stretching a strip of temporal fascia & suturing
• Creation Of Mechanical Obstacle:
  • Osteotomy on an eminence by Lindermann
  • Placement of graft over eminence by Mayor
  • Osteotomy on the zygomatic arch by Dautry

Dautry’s Zygomatic Arch Osteotomy:

Mayor’s Grafting Technique On The Eminence:

• Direct Restrain Of Condyle: Temporalis fascia turned down & sutured
• Creation Of New Muscle Balance: Temporalis tendon divided & sutured in a horizontal manner
• Removal Of Mechanical Obstacles:
  • Meniscectomy: Torn meniscus is removed
  • High Condylectomy: Excision of the superior portion of the condyle
  • Eminectomy: Excision of the articular eminence

Question 2. Enumerate causes of inability to open the mouth. How to treat a case of bony ankylosis.
Or
Trisums causes
Answer:

Trisums causes is a condition in which muscle spasm prevents the opening of the mouth

Causes Of Inability:

• Orofacial infection
• Trauma
• Inflammation
• Myositis
• Tetany
• Tetanus
• Neurological disorders
• Drug-induced
• Extra articular fibrosis
• Mechanical blockage

Management Of Bony Ankylosis:

1. condylectomy:

• Pre-pre-auricular incision given
• Horizontal osteotomy cut given over condylar neck Condylar head is separated
• Smoothened the remaining structures
• Close the wound in layers
• If required bilateral condylectomy done

1. Exposure of the condylar head via a preauricular incision
2. Sectioning of the condylar head
3. Breaking the fibrous adhesions
4. Condylectomy complete
5. Suturing the capsule
6. Final skin suturing

2. Gap Arthroplasty:

• Two horizontal cuts are given
• Removal of bony wedge between glenoid fossa & ramus

3. Interposition Arthroplasty:

• Creation of gap
• Insertion of barrier(autogenous or alloplastic)

Kaban’s Protocol:

• Early surgical intervention
• Aggressive resection
• Ipsilateral colectomy
• Contralateral colectomy
• The lining of the glenoid fossa with temporalis fascia
• Reconstruction of ramus with costochondral graft
• Early mobilization
• Regular follow up

Question 3. Define ankylosis of TMJ. Mention etiology, clinical features
Or
Define & classify ankylosis of TMJ. Write on etiology, clinical features 
Or
Classify the Ankylosis of the Temporo-Mandibular Joint. Discuss the etiology of the Temporo-Mandibular Joint.
Or
Etiology and clinical features of TMJ ankylosis and Pathogenesis
Answer:

Definition:

Ankylosis means ” Stiff joint”

Etiology Of Ankylosis Of TMJ:

• Trauma, Congenital
• Infections -Osteomyelitis
• Inflammation, Osteoarthritis
• Rare causes, Measles
• Systemic diseases, Typhoid
• Other causes, Prolonged trismus

 Clinical Features Of Ankylosis Of TMJ:

1. Unilateral:
   • Deviation of the chin on the affected side
   • The fullness of the face on the affected side
   • Flatness on the unaffected side
   • Crossbite
   • Angle’s classic malocclusion
   • Condylar movements absent on the affected side
2. Bilateral:
   1. Inability to open mouth
   2. Neck chin angle reduced
   3. Class II malocclusion
   4. Protusive upper incisors
   5. Multiple carious teeth

Pathogenesis Of Ankylosis Of TMJ:

Question 4. Diagnosis of Bilateral Ankylosis in an 8-year-old boy
Answer:

Diagnosis:

• Radiographic Features:
  • Complete obliteration of joint space
  • Normal TMJ anatomy is distorted
  • Deformed condylar head
  • Elongation of the coronoid process

Grading:

Temporomandibular Joint Disorders Short Essays

Question 1. Pathogenesis and Treatment
Answer:

Pathogenesis:

Pathogenesis Treatment:

• May resolve on its own
• Manipulation of the jaw by jaw stretcher

Question 2. Internal derangement of TMJ.
Answer:

Definition of TMJ:

TMJ is the anteromedial displacement of the interarticular disc associated with the posterosuperior displacement of the condyle in the closed jaw position

Features  Of TMJ:

• Pain on biting
• Clicking sound over the joint
• Deviation of mandible
• Restricted mouth opening due to pain

Management Of TMJ:

1. Anterior repositioning appliances
   • Placed on occlusal surfaces
2. Supportive therapy
   • NSAIDs to relieve pain
   • Heat application
3. Occlusal correction

Question 3. Pain dysfunction syndrome/ MPDS.
Answer:

Pain Dysfunction Syndrome

• Pain Dysfunction Syndrome is a disorder characterized by facial pain limited to the mandibular function, muscle tenderness, joint sounds, absence of significant organic & pathologic changes in TMJ
• Pain Dysfunction Syndrome may be due to functional derangement of dental articulation, psychological state of mind, or physiological state of joint
• Coined by Laskin

Etiology of Pain Dysfunction Syndrome:

1. Extrinsic Factors:
   • Occlusal disharmony
   • Trauma
   • Environmental influences
   • Habits
2. Intrinsic Factors:
   • Internal derangement of TMJ
   • Anterior locking of disc
   • Trauma

Features Of Pain Dysfunction Syndrome:

• Unilateral preauricular pain
• Dull constant sound
• Muscle tenderness
• Clicking noise
• Altered jaw function
• Absence of radiographic changes
• Absence of tenderness in ext. auditory meatus

Management Of Pain Dysfunction Syndrome:

1. Reassurance
2.  Soft diet
3. Occlusal correction: 7 ‘R’s
   • Remove-extract the tooth
   • Reshape grind the occlusal surface
   • Reposition orthodontically treated
   • Restore conservative treatment Replaceby prosthesis
   • Reconstruct TMJ surgery
   • Regulate control habits
4. Isometric exercises
   • Opening & closing of mouth 10 times a day
5.  Medicaments
   • Aspirin: 0.3-0.6 gm/4 hourly
   • NSAIDS: for 14-21 days
   • Pentazocine: 50 mg/ 2-3 times a day
6. Heat application
   • It increases circulation
7.  Diathermy
   • Causes heat transmission to deeper tissues
8.  LA injections
   • 2% lignocaine into trigger points
9. Steroid injection
   • As anti-inflammatory
10. Anti-anxiety drugs
    • Diazepam-2-5 mg * 10 days
11. Tens
12. Acupuncture

Question 4. Preauricular approach to TMJ.
Answer:

Preauricular Approach To TMJ

Basic & standard approach to TMJ

Technique Of TmJ:

• Shaving of the area
• Mark incision from the helix of the ear to the upper border of the tragus
• The depth of penetration of the incision should be upto superficial layer of the temporalis fascia
• Exposure of condyle, thus advantageous

1. Initial incision in the preauricular fold
2. Oblique incision through the superficial layer of temporalis fascia. The periosteal elevator is then inserted below the temporalis muscle to expose the lateral portion of the zygomatic arch
3. Cut in the capsule to enter the TMJ space and incision through the lateral attachment of the disc, entering the inferior joint space
4. After surgery, suturing of the capsule
5. Suturing the wound in layers
6. Final skin subcuticular suturing

Question 5. Risdon’s approach.
Answer:

Risdon’s Approach

1. Site Of Incision: 1 cm below the angle of the mandible
2. Extent: Forward, parallel to the lower border of the mandible
3. Site Seen: Neck of condyle & ramus

Disadvantages Of Risdon’s Approach:

• Poor access to the condylar head
• Procedures involving the articular portion of the head & meniscus cannot be performed

Question 6. Frey’s Syndrome:
Answer: 

Frey’s Syndrome

This is auriculotemporal nerve syndrome

Causes Of Frey’s Syndrome:

• Iatrogenic causes followed by parotidectomy

Features Of Frey’s Syndrome:

• Pain in auriculotemporal nerve distribution
• Gustatory sweating
• Flushing on the affected side

Diagnosis Of Frey’s Syndrome:

• Positive starch iodine test

Treatment Of Frey’s Syndrome:

• Topical application of anticholinergic
• Radiation therapy
• Surgical procedures
• Skin excision
• Nerve section
• Tympanic neurectomy

Temporomandibular Joint Disorders Short Answers

Question 1. Arthroscopy.
Answer:

Arthroscopy

• Means looking into the joint
• Oral And Maxillofacial Surgery

Indications Of Arthroscopy:

1. Disc derangement
2. Arthrosis Arthritis
3. Injuries to TMJ
4. Perforation of the disc

Contraindications Of Arthroscopy:

• Infection
• Ankylosis

Components Of Arthroscopy:

• Arthroscope
• Fibreoptic light cables
• Eye lens

The procedure Of Arthroscopy:

• Anesthetized
• Palpate the joint
• Mark a point at the 12 mm anterior to the tragus
• Mark another point 1-2 mm below it
• Cutaneous incision made
• Introduction of the trocar into the capsule
• Continuous irrigation carried throughout the procedure

Question 2. Barrel bandage.
Answer:

Barrel Bandage

• Used for ankylosis management
• The bandage is used to restrict the movement of the joint
• The patient is kept on a soft diet
• Restrict wide opening of the mouth while yarning, laughing
• If required, support the mandible while such activities

Question 3. Interposition arthroplasty.
Answer:

Interposition Arthroplasty

• Used for the management of ankylosis
• Horizontal osteotomy cut is made
• Between two cuts, graft material is added

Various Grafts Are:

1. Autografts:
   • Cartilaginous graft
   • Temporalis fascia
   • Temporalis muscle
2. Heterogenous Graft:
   • Pig bladder
3. Alloplasts:
   • Stainless steel
   • Titanium
   • Zirconium
   • Tantalum

Question 4. Eminectomy.
Answer:

Eminectomy

Excision of the articular eminence

Steps Of Eminectomy:

• Anesthetized
• Undermine & turn skin & subcutaneous flap upward
• A small horizontal incision was given over the zygomatic arch
• T incision is given a horizontal portion over the arch & vertical portion over the apex of the eminence.
• Periosteum reflected
• Expose eminence
• A series of bur holes are created
• Burs are connected
• Eminence is sectioned & separated
• Smoothened the base of eminence Irrigate the area
• Suture

Question 5. Ligaments of TMJ:
Answer:

Ligaments Of TMJ

1. Temporomandibular ligament
   • It stabilizes TMJ
   • It extends downward & backward from the articular eminence to the external & posterior sides of the condylar neck
2. Stylomandibular ligament
   • Extends from the styloid process to the mandibular angle
3. Sphenomandibular ligament
   • Arises from the spine of the sphenoid & is inserted into the lingual of the mandible
   • It is a remnant of Meckel’s cartilage

Temporomandibular Joint Disorders Viva Voce

1. The submandibular incision is given about 1 cm below the angle of the mandible
2. Hemarthrosis is the extravasation of blood into joint space due to trauma
3. Intraarticular injection of hydrocortisone reduces the inflammatory process within the joint
4. The preauricular approach is an ideal surgical approach to TMJ ankylosis
5. The interposition of temporal muscle and fascia in the treatment of ankylosis is done to prevent ankylosis
6. Dautery procedure is a treatment modality for TMJ dislocation
7. Bird face appearance is a feature of bilateral ankylosis
8. A hypertonic saline para capsular injection is used for conservative management of TMJ subluxation and dislocation
9. MPDS is the most common disorder causing pain in the masticatory apparatus along with TMJ