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BDS5 oral disease > TMJ > Flashcards

TMJ Flashcards

1
Q

common presentation of TMJ pain (socrates)

A

S = TMJ, MOM, ear
O = sudden or gradual
C = aching, deep +/- acute sharp flares
R = ear, angle of jaw, temple, teeth
A = parafunction, occlusal issues
T = continuous +/- acute flares
E
- chewing, yawning, prolonged mouth opening
- rest and analgesia can help
S = variable

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2
Q

give some differential diagnoses for TMJ pain (anatomical sieve, up to 6)

A
  • dental = caries, cracked tooth
  • sinus = sinusitis
  • vascular = giant cell arteritis
  • neuropathic = TN, TACs
  • headache = tension, migraine
  • malignancy
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3
Q

describe giant cell/temporal arteritis (what, age, s/s, management)

A
  • vasculitic condition, medical emergency
  • > 50yo
  • unilateral
  • jaw claudication, tenderness over temporal region, frequent severe headaches, vision issues (double, loss)
  • may lead to blindness
  • needs to go to A&E urgently for high dose corticosteroids (preserve vision)
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4
Q

how does trigeminal neuralgia pain usually present?

A
  • paroxysmal unilateral lancinating pain with refractory periods
  • affecting ≥1 dermatomes of trigeminal nerve
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5
Q

briefly describe the anatomy of the TMJ (3)

A
  • temporal aspect = S shaped with articular eminence and glenoid fossa, covered with fibro-cartilage
    – articular fossa deepens with age until adulthood
  • ellipsoid-shaped condyle connected to mandible by narrow neck
    – convex rounded/flattened mediolateral surface with “poles”
  • biconcave fibrocartilage articular disc
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6
Q

what are the three movements of the condyle on mouth opening?

A
  • hinge/rotation (up to 20mm)
  • translation
  • secondary rotation
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7
Q

how may the TMJ be imaged? (6)

A

bony:
- panoramic/DPT (open and closed views)
- CBCT
- facial bone views = PA condyles, reverse Townes, etc
- medical CT
- nuclear medicine (hyperplasia, tumours)
soft = MRI (US limited for TMD)

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8
Q

what are the pros and cons of using DPT to view TMJ? (3/5)

A

+:
- open and closed views (open less likely to show superimposition)
- simple
- tomographic (overcomes superimposition issues)
-:
- superimposition may prevent view of articular surface
- oblique view (not true lateral)
- lacks sharp detail
- normal DPT = protruded position
- cannot see soft tissue

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9
Q

what are the different types of disorders affecting the TMJ? (5)

A
  • developmental = hypo/hyperplasia, bifid
  • trauma, dislocation, fracture
  • inflammatory or degenerative
  • neoplastic
  • TMD (temporomandibular dysfunction/myofascial pain dysfunction syndrome)
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10
Q

describe condylar hypoplasia (presentation, association, radiograph)

A
  • unilateral with asymmetry
  • commonly seen with hemifacial microsomia
    radiograph:
  • small condyle, thin condylar neck with backward curvature
  • antegonial notching of lower border of mandible (increased muscle activity)
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11
Q

describe hemifacial microsomia (what, s/s)

A
  • developmental H&N anomaly
  • decreased growth and development of face, typically unilateral
  • first and second branchial arches (maxilla, mandible, zygoma, ear)
  • shortened ramus, hypoplastic or rudimentary condyle, elongated coronoid
  • facial asymmetry, malocclusion, delayed tooth eruption
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12
Q

describe condylar hyperplasia (what, demographic, s/s)

A
  • unilateral, enlargement of head or elongated condylar neck
  • condyle keeps growing after puberty (cartilage), self-limiting
  • post-puberty, females
  • mandibular asymmetry with posterior open bite
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13
Q

describe bifid condyle (aetiology, appearance)

A
  • possibly developmental or traumatic
  • asymptomatic incidental finding
  • vertical depression/notch on condylar head
  • may resemble tumour but has normal cortical outline and cancellous bone
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14
Q

give 3 developmental abnormalities of the condyle

A
  • hypoplasia
  • hyperplasia
  • bifid condyle
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15
Q

what are the two traumatic disorders of the TMJ?

A

dislocation
fracture

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16
Q

describe dislocation injury of the TMJ (what, presentation, causes)

A
  • displacement of condyle to a position anterior to the articular eminence but within the capsule, such that the mouth remains in the open position
  • elongated facial appearance with notch just anterior to ear
  • due to acute trauma (blow whilst mouth open) or yawning, mandibular XTNs, prolonged RCT
  • chronic - neuromuscular imbalance, lax capsular ligaments, flat articular eminence
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17
Q

define dislocation injury of the TMJ

A
  • displacement of condyle to a position anterior to the articular eminence but within the capsule
  • such that the mouth remains in the open position
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18
Q

what may increase the risk of chronic TMJ dislocation? (3)

A
  • neuromuscular imbalance
  • lax capsular ligaments
  • flat articular eminence
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19
Q

what type of fracture(s) is likely from a blow to the chin point?

A

bi or unilateral fracture

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20
Q

what type of fracture(s) is likely from a blow to the side of the mandible?

A
  • fracture at point of impaction
  • AND of opposite condylar neck (contrecoup fracture)
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21
Q

why are many condylar fractures “displaced”?

A

muscle pull (usually forward and medially by lateral pteryoid)

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22
Q

are intra or extracapsular TMJ fractures more common?

A

extracapsular (condylar neck is a weak point)

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23
Q

how may TMJ fractures present? (3)

A
  • pain and swelling over the affected TMJ, or minimal symptoms
  • deviation of mandible to affected side on opening
  • possibly anterior open bite if bilateral condylar fracture
24
Q

what imaging may be used to view TMJ fractures?

A
  • often DPT and PA condyles or reverse Townes (2 views at right angles)
  • +/- CBCT/medical CT
25
Q

what radiographic signs may indicate degenerative joint disease (TMJ)? (4)

A
  • irregular condyle outline, erosions of articular surface of condyle or osteophyte formation
  • loss of cortication
  • RL beneath condylar head (Ely cyst/subchondral RL)
  • bony sclerosis (increased density, inflammatory response)
26
Q

describe degenerative TMJ disease (s/s, age, radiograph)

A
  • similar symptoms to TMD + grating sound/sensation (crepitus) on palpation
  • usually local disease > generalised
  • older adults
    radiograph
  • irregular condyle outline, erosions of articular surface of condyle or osteophyte formation
  • loss of cortication
  • RL beneath condylar head (Ely cyst/subchondral RL)
  • bony sclerosis (increased density, inflammatory response)
27
Q

describe myofascial pain (TMJ) (what, examination)

A
  • tenderness of facial and neck muscles (mainly MOM), can be associated with stress, bruxism or following dental tx
  • palpate MOM, IO signs of bruxism
  • no imaging usually needed
  • managed conservatively first
28
Q

what is disk displacement/internal derangement of disk (TMJ)? (what, any associations)

A
  • disk anteriorly displaced when the mouth is closed
  • on opening, disk reduces back to normal position with a click or stays anterior (reduced MO)
  • may be associated with myofascial pain
  • no abnormal bony changes
    (may use MRI if unresponsive to treatment)
29
Q

what are the two different types of disk displacement (TMJ)?

A
  • anterior displacement with reduction (normal mouth opening, click as disk reduces to normal position)
  • anterior displacement without reduction (reduced MO, disk stops condyle moving forward)
30
Q

describe ankylosis of TMJ (what, s/s, types, investigation)

A
  • fusion of condyle to temporal or zygomatic bone
  • progressive decrease in mouth opening, limited/no condylar movement
  • fibrous or bony
  • altered radiographic outline needing CBCT or CT
31
Q

give possible aetiologies of TMJ ankylosis (up to 8)

A
  • congenital
  • inflammatory (eg suppurative arthritis)
  • trauma
  • neoplastic
  • scleroderma (autoimmune)
  • radiation therapy
  • TMJ operations
  • idiopathic
32
Q

what is the difference between intrinsic and extrinsic TMJ tumours?

A
  • intrinsic = from within joint
  • extrinsic = from outside TMJ but involve the TMJ
33
Q

give 3 examples of benign tumours affecting the TMJ, which is the most common?

A
  • osteochondroma most common
  • chondroma
  • giant cell granuloma
34
Q

how may osteochondroma affecting the TMJ present? (clinical, radiograph)

A
  • slow-growing
  • swelling
  • asymmetry
  • limited mouth opening
  • irregularly shaped radiopaque enlargement of condyle (usually anterior aspect)
35
Q

give 3 examples of malignant tumours that may affect the TMJ, which is the most common?

A
  • secondary deposits most commonly
  • chondrosarcoma
  • osteosarcoma
36
Q

how may malignant tumours affecting the TMJ present? (clinical, radiograph)

A
  • pain, discomfort
  • restricted mouth opening
  • swelling
  • bone destruction = RL with loss of condyle definition
37
Q

why is it especially important to diagnose malignant TMJ tumours early?

A

to limit the likelihood of spread into the middle cranial fossa

38
Q

describe the epidemiology of TMD (gender, type, age)

A
  • more in females
  • most are recurrent, some are single episode or persistent
  • s/s peak at 20-40yo
39
Q

what is the difference between acute and chronic TMD?

A
  • acute = short duration, self-limiting, often linked to specific trigger (stress, trauma)
  • chronic = >3 months and may fluctuate
40
Q

define temporomandibular disorders

A

collective term of musculoskeletal problems involving the MOM, TMJ and associated structures

41
Q

what are the MOM diagnostic criteria for TMDs?

A
  • myalgia (one muscle), myofascial pain (muscle and fascia) +/- referral, regional pain (multiple muscles)
    (tender to palpation, possible limited mandibular function due to pain)
42
Q

what are the TMJ diagnostic criteria for TMDs? (7)

A
  • arthralgia, temporal area headache
  • disk displacement disorders
  • inflammatory disorders (capsulitis, arthritis)
  • dislocation, fracture
  • deviation in form
  • ankylosis
  • tumour
43
Q

how may myalgia/myofascial pain present (TMD)? (history, 4)

A
  • regional, dull aching pain at rest, aggravated during function - masseter and temporalis
  • more painful in morning (nocturnal parafunction)
  • referral of pain = headache, fullness of ear, neck pain
  • possible limitation of movement
44
Q

how may arthralgia present (TMD)? (history, 5)

A
  • localised sharp pain, aggravated during loading and function
  • around the TMJ, surrounding tissues and ear
  • associated with (not caused by) displaced/dysfunctional disk
  • possible limitation of movement
  • +/- generalised arthritis, often with crepitus
45
Q

describe the aetiology of TMDs

A
  • genetics, female
  • peripheral and central sensitisation
  • comorbidities - fibromyalgia especially
  • biopsychosocial: (onset, development and maintenance of chronic pain)
    – parafunction, chewing gum
    – trauma, inflammatory disease, occlusion
    – stress, anxiety, hypervigilance, catastrophising
    – race/ethnicity, SE factors, pt beliefs
46
Q

describe the 3 step examination protocol for TMDs

A

1 Joint examination
- any pain on TMJ palpation or wide opening
- any joint sounds
2 Muscle examination
- neck/shoulder muscles
- masseter and temporalis (EO)
- insertions of lateral and medial pterygoids (IO) + TSL, signs of parafunction, occlusal derangement, high restorations
3 Functional examination
- deviation and pattern of mouth opening and excursions
- >30mm functionally sound

47
Q

what is normal mouth opening (mm)?

A

35-45mm between incisors (3 of pt’s fingers)
(>30mm functionally sound)

48
Q

what are the three phases of TMD management?

A
  • phase I = reversible conservative tx
    phase II = irreversible management (minimal evidence)
    phase III = irreversible treatment
49
Q

describe phase I of TMD management (8)

A

(reversible, conservative)
- pt education - facilitate engagement, develop coping skills, reassurance, signposting, informative prescription
- analgesia - mostly OTC, benzodiazepines for acute pain
- jaw exercises, physiotherapy
- relaxation, mindfulness, CBT, decrease stress
- acupuncture (short term, good for masseter)
- bite raising appliance (soft or Michigan splint)
- heat/cold application
- pharmacological management

50
Q

what pharmacological means may be used in phase I management of TMDs? (3)

A
  • acute = paracetamol, NSAIDs (esp topical), short course of benzodiazepines (trismus)
  • chronic = tricyclic antidepressants used off-label by specialist or GP (11-12 weeks before effective)
  • botox may help for dislocations or hypertrophic muscles
51
Q

what is involved in the education part of phase I management of TMDs? (7)

A
  • facilitating pt engagement
  • developing coping skills
  • reassurance
  • signposting
  • informative prescriptions
  • what TMD is and how it causes pain
  • avoiding parafunctional habits (chewing gum or pens, soft diet), resting muscles
52
Q

what may be involved in phase II of TMDs management? (4)

A
  • occlusal therapy and restorative treatment
  • prosthodontic reconstruction
  • orthodontics
  • surgery (orthognathic if severe skeletal discrepancy)
53
Q

what additional specialist treatments may be used for chronic/unresponsive TMDs? (5)

A
  • muscle relaxants (baclofen, diazepam)
  • intramuscular or intra-articular LA (dx and tx)
  • intra-articular steroids (depo-medarone) - long term associated with condylar hypoplasia
  • arthroscopy/arthrocentesis often with steroids
  • joint surgery only if serious functional issues
54
Q

when might joint surgery be indicated for TMDs? (4)

A
  • mandibular growth disturbances
  • ankylosis
  • tumours
  • secondary conditions - arthritis, fracture of condyle with dislocation, anterior disk displacement with severe functional issues, recurrent mandibular dislocation
55
Q

name some of the types of extra-articular TMJ surgery (4)

A
  • condylotomy
  • condylectomy
  • whole joint replacement
  • orthognathic surgery
56
Q

what is involved in phase III TMDs management?

A

diagnostic and therapeutic TMJ arthroscopic surgeries

BDS5 oral disease (26 decks)

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