BONY

ANATOMY

 Saggital aspect

coronal aspect

Glenoid fossa & articular eminence

TMJ CORONAL VIEW
ARTICULAR CARTILAGE
TMJ LATERAL VIEW
SOFT TISSUE ANATOMY

TMJ capsule
TMJ ligaments
Disc(meniscus)
Synovial membrane
TMJ LIGAMENTS
CAPSULAR LIGAMENT
(LATERAL VIEW)
 TMJ WITH
MUSCLE
ATTACHMENT
 TEMPORALIS MUSCLE
(WITH ZYGOMATIC ARCH & MASSETER MUSCLE REMOVED)
MASSETER MUSCLE
LATERAL & MEDIAL PTERYGOID
Blood supply-
Branches from Superficial
temporal & Maxillary Artery

Nerve supply-
Auriculotemporal
& Masseteric Nerve
TMJ PATHOLOGY – PT’S HISTORY
 TMJ PATHOLOGY , PATIENT'S HISTORY
 Age - Younger-MPDS common
Older degenerative disease common

 Occupation -
Higher class people

 H/O pain - MPDS - dull & morning time

TMJ pain - Sharp & increased
during function

 Jaw & joints symptoms

 Oral habit : Bruxism
Chewing pattern

 Medical history : Rheumatoid arthritis

Extraction
Trauma

 H/O : Headache
Back pain
Ear ache

Family history : Rheumatoid arthritis

Osteoarthritis
CLINICAL EXAMINATION

 Facial symmetry
 Mouth opening
 TMJ palpation
 Muscle palpation
 Dental examination
 MYOFASCIAL PAIN
DYSFUNCTION SYNDROME
or
MASTICATORY MYALGIA
or
COSTEIN’S SYNDROME
or
TMJ ARTHROSIS
MPDS is a pain disorder, in which unilateral
pain is reffered from the trigger points in
myofacial structure, to the muscles of the
head n neck.
pain is constsnt, dull ache I
contrast to sharp shooting , intermittent
pain of neuralgias(chronic pain). But the
pain may range from mild to intolerable.
 history
 Occlusion theory : costen ( 1934 )
he reported association of bite closure
(due to loss of posterior teeth) with symptoms
like ear pain,sinus pain, decreased hearing,
tinnitus, dizzinus, burning n vertigo n occipital
headaches(bite raising era)

Psychophysiologic theory: laskin (1969)

he states that psychologic stress leads
to myospasm (tranquilizers,muscle relaxants)
 SYMPTOMS OF MPDS
 CARDINAL SYMPTOMS:-
 pain or discomfort in head or neck
 Limitation of the motion of the jaw
 Joint noises-grating , clicking , snapping
 Tenderness to palpation of muscle of
mastication.
 Associated symptoms:-
 Neurologic– tingling , numbness
 G I track – nausea , vommiting, diarrhoea
 Musculo skeletal – fatigue, tention, shift jt. Pain
 Otologic – ear pain, dizziness, vertigo
 MANANGMENT:
Initial treatment & recommendation may include

1) spray & stretch.

Fluoromethane refrigerant spray
2) Injection of trigger point.
.
3 ) a relatively soft diet

4) Medications:- aspirin, piroxicam, ibuprofen, pentazocine,

methacarbamol, amitryptiline.

5) Discontinuing of daytime any para functional habits.

6) Diazepam. 2 mg for 2 week.

Anxiety reducing & muscle relaxant properties
6) occlusal splint.
stabilization & relaxation splints
Adv. Greater freedom in mandibular movement & to
increase muscle balance.
Disadv. Cause extrusion of posterior teeth results in
open bite.

7) Physical therapy.
ultra sound(0.7 to 1.0 watts/cm2 for 10 min. every
alternate day)
moist heat(with towel for 15 to 20min.4 times a day)
occlusal adjustment.
active stretch exercises.
8) Biofeedback.
9) TMJ arthrocentesis
10. TENS [transcuteneous electric nerve
stimulation]
M/A.
1) neurological action.

2) Physiologic effect.

3) pharmacological action.
Stimulate release of endorphins, which
are endogenous morphine like substens.

4) Placebo effect.
DIAGNOSTIC STUDY
Plain radiography:
Trans orbital view or antero-posterior view.
 Trans cranial or lateral view.
 Trans pharyngeal
 Reverse towne’s
 Cephalometric
 Water’s view
 Xeropadiography

Conventional tomography:

 Orthopantamography
 Linear tomography
 Corrected tomography
 Computed tomography;

Adv. It provide superior osseous anatomical images

without any superimposition than conventional x-
ray.And in different plane.
e.g. axial
saggital
coronal
It is good for hard tissue.

Disadv. Can’t asses dynamic depiction of soft tissue

components.
( MRI )

Adv. - Doesn’t use ionising radiation.

non invasive
excellent for soft tissue

Disadv. - very expensive

patient discomfort
Arteriography:-
defect in position or structureof the join
disc & its attachment can be determined using
arthrography.
arthrography is performed by injecting the
contrast madia in to the joint space and after it
radiograph is taken.
Arthroscopy

Electromyography
INTRACAPSULAR DISORDES OF TMJ

1) INTERNAL DEARANGMENT OF TMJ.

2) TMJ ARTHRITIS or DEGENERATIVE JOINT DISEASE

Internal derrangement of TMJ

It is abnormal relation between disc &condyl &

articulr eminence.

May be asymtomatic or abnormal joint sound.

Limitaion mouth opening or pain.

Doesn’t affect children less than 5 yrs.

Loose disc is most commonly ant. & medially

displaced because pull of lateral pterygoid.
 Etiology :
Chronic low grade micro trauma
e.g. bruxism

Direct trauma to mandible

Malocclusion

Luxiety of joint
 Types :

1. Anterior disc displacement.

With reduction. Without reduction

2)Posterior disc displacement.

Treatment:
1. occlusal splint
Stabilization with flat plain, hard condyle
Full coverage splint

Helps to unload the joint and prevent

Further disc displacment.

2) Arthrocentesis
(lavage of joint)
  TMJ ARTHRITIS /
OSTEOARTHRITIS /
DEGENERATIVE JOINT DISEASE
  Definition:
Disease articular cartilage and
subchondral bone with
secondary
infection of synovial membrane.
 Aetiology:

Primary
secondary

Unknown but role of genetic. – chronic microtrauma

- metabolic disease
 • clinical feature:
 Symptomatic Asymptomatic

 Unilateral pain over condyle

 Limitation of mouth opening
 Crepitus
 Feeling of stiffness
 • Radiographic findings:
 Narrowing of joint space
 Flattening of articular surface
 Osteophytic formation
 Anterior lipping of condyle
 Presence of ELY’s cyst.(subchondral cyst)
 Treatment:

Conservative surgery
-NSAIDs -arthroplasty(removal of
osteophyte
-soft diet & erosion area of bone)
-intra articular steroid -high condylectomy-
occlusal splint -replacment
 DISLOCATION OF
TMJ
Definition:
complete seperation of articular
surface with fixation in abnormal

position.
 Etiology
Intrinsic trauma Extrinsic trauma

Yawn  Blow to mandible

Vomiting  During intubation in GA.
Singing  Dental extraction
Laughing
Seizure
 Clinical feature
 Bilateral involvement

 Pain(due to spasm)
 Hollow in front tragus in bilateral site
 Lateral pole of condyle is prominent
 Open bite
 Protruding chin
 Difficulty in speech
2. Bilateral involvement

Pain(due to spasm)
Hollow in front tragus in bilateral site
Lateral pole of condyle is prominent
Open bite
Protruding chin
Difficulty in speech
 Management
 Manual reduction by
downward,backward,upward movement.

Surgical procedure include:

 Bone grafting to eminence
 Eminence reduction
 Lateral pterygoid myotomy.
 TMJ ANKYLOSIS
 Definition:
it is Greek word means stiff joint or
abnormal mobility or consolidation of
joint
 Classification:
By kazanzian in 1938
1 based on location.

Intra articular extra articular

2. based on type of tissues involvement.

bony fibrous fibroosseus

3. based on extent of lesion.

Complete
incomplete
 Etiology:
 True ankylosis
 direct blow over joint, blow on chin

 Birth trauma

 Infection
-middle ear cavity infection
-acute pyogenic arthritis
-otitis media
-mastoiditis

 Inflammation
-Rheumatoid arthritis
-Osteo arthritis
-Scarlet fever
False ankylosis:
muscular trismus
muscular fibrosis
myositis ossificans
tetany
tetanus
neurogenic cause
drug indused
# of zygomatic arch
bands of scar tissues
 Clinical features:
 Inability to open jaw
 Difficulty in mastication
 Compromised oral hygiene & speech
 Premature contact of posterior teeth so
open bite
 retrognathia
 retrogenia(weak chin)
 Prominent antegonioan notch
Radiographic examination
x-ray for TMJ both in open & closed mouth us
taken.
In fibrous ankylosis joint space is visible
but no movement of condyle is seen where as
in bony ankylosis a bony mass is seen in the
area of joint with obliteration of joint space.
 Management
 Aim:

 Removal of ankylosed mass of bone to

mobilise jaw
 Reconstruction of joint & maintenance of
vertical height of ramus
 Prevention of recurrence.
 Restoration of occlusion & maintenance of
function
Surgical approach to TMJ:

Pre auricular
Post auricular
End aural
Temporal
Trans coronal or question mark approach
submandibular incision
 Techniques:
 CONDYLECTOMY:
it involve excision of the condyle in
cases of partial fibrous ankylosis whre
some articular space is still persisting.
 Disadv. Pseudoarthrosis(flail joint)
develop as healing occure.
GAP ARTHROPLASTY:

is a tech. Of resecting segment of of bone between

base of the skull and the site of entry of inferior
dentel nerveinto manbular ramus area.

Disadv. - Creation of pseudo articulation & short

ramus
risk of ankylosis
premature occlusion
anterior open bite
INTERPOSITIONAL ARTHROPLASTY:

In this tech. Some material interposed

between bony fragments for preventing
reunion.
~ autogenous material
-temporalis fascia
-perichondrium
-Skin graft
-Fascia lata
~ alloplastic material
-Acrylic resin
-tentanium foil