TMD/ Facial Pain Flashcards
When assessing the efficacy of myofascial trigger points injections what substance should be used as a control? A. Xylocaine B. Sterile water C. Dry needling of the trigger point D. Normal saline
Answer: D
Rationale:
Normal saline is used as the control in studies of efficacy of trigger point injection solutions.
Reference:
Byrn C, Olsson J, Falkheden L, Lindh M, Hosterey U, Fogelberg MN, Linder LE, Bundertorp O. Subcutaneous sterile water injections for chronic neck and shoulder pain following whiplash injuries. Lancet, 1993;341:449-52.
Which of the following classes of drugs may provide benefits of both analgesia and reduction of bruxism in the myofascial pain patient?
A. Monoamine oxidase inhibitors
B. Tricyclic antidepressants
C. Nonsteroidal anti-inflammatory medications D. Selective serotonin reuptake inhibitors
Answer: B
Rationale:
Tricyclic antidepressants, including specifically amitriptyline, have been suggested to be effective in alleviating pain in chronic pain syndromes and in reducing bruxism by an unknown mechanism. None of the distractors have been shown to decrease bruxism. SSRI’s may increase bruxism.
Reference:
Karlis, V and Glickman, R. Nonsurgical management of temporomandibular disorders. In Miloro, M (ed). Peterson’s Principles of Oral and Maxillofacial Surgery, 2nd ed. 2004 Hamilton: BC Decker p. 953.
Comparison of outcomes one year after arthroscopy, discectomy, modified condylotomy, and disc repositioning surgery for TMJ internal derangement is most correctly summarized by which of the following statements?
A. Superior pain relief and diet improvement after arthroscopy
B. Statisticallyindistinguishablepainreliefanddietimprovement
C. Superior pain relief and improved diet after disc repositioning surgery D. Statisticallyindistinguishablerangeofmotion
Answer: B
Rationale:
A prospective investigation comparing outcomes one year after arthroscopy, discectomy, condylotomy, and disc repositioning for internal derangement showed no statistically significant differences in pain reduction or diet improvement. Greater improvement in contralateral range of motion occurred with condylotomy and arthroscopy, presumably due to intracapsular scarring following discectomy and disc repositioning.
Reference:
Hall HD, Indresano TA, Kirk WS, et al. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg 2005;63:1174-1179
Which statement most accurately describes the TMJ disc?
A. Convex superior surface, concave inferior surface
B. Composed primarily of Type-2 collagen
C. Biconcave cross-sectional morphology
D. Composed of hyaline cartilage
Answer: C
Rationale:
In cross section the disc has a biconcave shape. This shape enhances load distribution between the surfaces of the condyle and temporal bone. The disc is composed of fibrous connective tissue. The disc has little or no innervation.
Reference:
Mohamed,S:Developmental and Clinical Anatomy and Physiology of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn PD (eds):Oral and Maxillofacial Surgery Vol 4. 2000, WB Saunders, Philadelphia, p 8.
Which of the following best describes the correct sequence of structures encountered superior to the zygomatic arch with a preauricular approach to the temporomandibular superior joint space?
A. Skin, superficial deep temporal fascia, temporoparietal fascia, subgaleal fascia, capsule
B. Skin, subgaleal fascia, temporoparietal fascia, temporalis fascia, capsule
C. Skin, temporoparietal fascia, superficial deep temporalis fascia, subgaleal fascia, capsule
D. Skin, temporoparietal fascia, subgaleal fascia, temporalis fascia, capsule
Answer: D
Rationale:
Temporoparietal fascia is continuous superiorly with galea. Subgaleal fascia is a discrete fascial layer deep to temporoparietal fascia. The layer immediately deep to subgaleal fascia is temporalis fascia. Temporalis fascia is immediately superficial to joint capsule.
Reference:
Politi M, Toro C, Cian R, Costa, F, et al. The deep subfascial approach to the temporomandibular joint. J oral Maxillofac Surg 2003;62:1097-1102.
Ellis EE, Fide MF. Surgical Approaches to the facial skeleton. Williams and Wilkins, Baltimore, 1995 p.167-911.
The auriculotemporal nerve:
A. originates from 2 roots surrounding the anterior deep temporal artery.
B. innervates the stapedius muscle.
C. innervates the lateral pterygoid muscle.
D. has communications with the otic ganglion.
Answer: D
Rationale:
The auriculotemporal nerve is one of several nerves provides sensation to the TMJ and a portion of the ear. Its origin is by two roots that surround the middle meningeal artery. The stapedius muscle is innervated by the facial nerve. The lateral pterygoid is innervated by pterygoid branches form the 3rd division of the trigeminal nerve. Auriculotemporal contributions to the otic ganglion supply afferent innervation to the parotid gland.
Reference:
Mohamed,S: Developmental and Clinical Anatomy and Physiology of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn PD (eds): Oral and Maxillofacial Surgery Vol 4, 2000, WB Saunders, Philadelphia, p. 14.
What statement is true about internal derangement of the TMJ?
A. Disc morphology is more important than disc position.
B. Disc mobility is more important than disc position.
C. Disc position is more important than disc mobility.
D. Disc morphology is more important than disc mobility.
Answer: B
Rationale:
Disc displacement may follow or precede alteration in the surface characteristics of the joint, although contemporary literature has discounted the importance of both disc displacement and the value of surgical disc repositioning. Impaired disc mobility is more closely related to alterations in the internal milieu of the joint and altered joint mechanics than is disc position. Disc displacement, though a marker of internal derangement, is probably not as important as altered disc mobility
Reference:
Dolwick, MF: Temporomandibular Joint Disc Displacement: A Clinical Perspective. In, Sessle, BJ; Bryant, PS; Dionne, RA (Eds): Temporomandibular Disorders and Related Pain Conditions. Progress in Pain Research and Management. Vol 4 1995 IASP Press. Seattle. pp.79 – 87.
Mercuri, LG and Laskin, DM: Indications for Surgical Treatment of Internal Derangements of the TMJ. Oral Maxillofac Surg Clin N Am 1994;6:223.
The temporal branch of the seventh cranial nerve is located in which soft tissue plane when approaching the TMJ via a preauricular approach?
A. Within the superficial temporal fat pad
B. Within the subcutaneous fat
C. Deep surface of the temporalis fascia
D. Deep surface of the temporoparietal fascia
Answer: D
Rationale:
The temporal branch of the facial nerve is most commonly found on the deep surface of the temporoparietal fascia and superficial to the temporalis fascia.
Reference:
Ellis, E, Zide, M: Surgical Approaches to the Facial Skeleton, Baltimore, 1995, Williams and Wilkins, pp. 167-168
In the preauricular approach to the TM joint what best describes the location of temporal branch of the facial nerve?
A. Deep to temporalis fascia, 8-35 mm anterior to the external auditory canal
B. Deep to temporoparietal fascia, 8-35 mm anterior to the external auditory canal
C. Deep to temporoparietal fascia, mean 3.5 cm anterior to the external auditory canal
D. Deep to temporalis fascia, mean 3.5 cm anterior to the external auditory canal
Answer: B
Rationale:
The main trunk of facial nerve exits from the skull at the stylomastoid foramen and subsequently enters the parotid gland. The temporal branch of the facial nerve emerges from the parotid gland and crosses the zygoma deep to or within the temporoparietal fascia to innervate the frontalis muscle in the forehead. The temporal branch crosses the zygomatic arch 8-35 mm (mean 2.0cm) anterior to the most anterior portion of the external auditory canal.
Reference:
Quinn P: Color atlas of temporomandibular joint surgery. 1988 Mosby St. Louis pps. 30- 31.
Ellis E, Zide: Surgical approach to the facial skeleton. 1995 Lippincott Williams & Wilkins, Baltimore pps. 163-185.
Al-Kayat A, Bramley P: Modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 1980;17:91.
MR image generation is a function of which mechanism?
A. Detection of tissue positron emission
B. Detection of tissue features as a radiofrequency signal
C. Detection of tissue gamma irradiation
D. Detection of ionizing radiation which has traversed the tissue
Answer: B
Rationale:
Choice A describes Positron emission tomography (PET). It is a nuclear medicine imaging technique which produces a three dimensional image or map of functional processes in the body. PET is a valuable technique for some diseases and disorders, because it is possible to target the radio-chemicals used for particular bodily functions. Choice C Describes Bone Scan. A bone scan is a nuclear medicine study to detect bone abnormalities. The patient is injected with a small amount of radioactive material and then scanned with a Gamma camera, a device sensitive to the radiation emitted by the injected material. Several gamma-emitting radioisotopes are used, one of which is technetium-99m. When administered to a patient, a gamma camera can be used to form an image of the radioisotope’s distribution by detecting the gamma radiation emitted. Such a technique can be employed to diagnose a wide range of conditions (e.g. spread of cancer to the bones).
Choice D Describes X-ray. X-rays are primarily used for diagnostic medical imaging and crystallography. X-rays are a form of ionizing radiation and as such can be dangerous. Ionizing radiation is a type of particle radiation in which an individual particle (for example, a photon, electron, or helium nucleus) carries enough energy to ionize an atom or molecule (that is, to completely remove an electron from its orbit). If the individual particles do not carry this amount of energy, it is essentially impossible for even a large flood of particles to cause ionization. These ionizations, if enough occur, can be very destructive to living tissue. By far, the most significant source of man-made radiation exposure to the general public is from medical procedures, such as diagnostic X-rays, nuclear medicine, and radiation therapy. Some of the major radionuclides used are I-131, Tc-99, Co-60, Ir-192, Cs-137. These are rarely released into the environment.
The American Board of Oral and Maxillofacial Surgery 102
2007 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)
Reference:
Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed., Copyright © 2001 Churchill Livingstone, Inc.
Low signal intensity on a T-1 weighted TMJ MRI is characteristic of which substance? A. Joint effusion
B. Marrow
C. Cortical bone D. Fat
Answer: C
Rationale:
Magnetic resonance imaging (MRI) is a noninvasive method of mapping the internal structure of the body which completely avoids the use of ionizing radiation and appears to be without hazard. It employs radiofrequency (rf) radiation in the presence of carefully controlled magnetic fields in order to produce high quality cross-sectional images of the body in any plane. It portrays the distribution of hydrogen nuclei and parameters relating to their motion in water and lipids.
The exposure of the tissue to a Radiofrequency (RF) radiation causes the nuclei in the lower energy state to jump to the higher energy state. MR Imaging is based on the observation of the relaxation that takes place after the RF pulse has stopped and subsequent return of the excited nuclei from the high energy to the low. In pure water, the T2 and T1 times are approximately identical. For biological material, the T2 time is considerably shorter than the T1 time. By varying imaging it is possible to weight the signal to produce T1-, T2- or PD-weighted (proton density) images. From a medical perspective, it means that MR Imaging can provide multiple channels to observe the same anatomy. For instance in a brain image, white matter appears in a light grey in T1 and a dark grey in T2. Grey matter appears grey in both images. The Cerebro-Spinal Fluid (CSF) appears black in T1 and white in T2. The background of the image (air) appears black in both images. Fluid matters such as edema and water appear white (or whiter) on the T-2 image compared to T-1, while bone will appear darker.
Reference:
Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed., Copyright © 2001 Churchill Livingstone, Inc. .
Which of the following structures lies in closest proximity to the medial aspect of the TMJ? A. Carotid artery B. Middle meningeal artery C. Internal jugular vein D. 3rd division of Trigeminal nerve
Answer: B
Rationale:
The mean distance from the outer aspect of the zygomatic arch to the middle meningeal artery has been reported as 31 mm (range: 21-43 mm). This vessel is located slightly forward of the center (i.e., depth) of the glenoid fossa (mean: 2.4 mm). The mean distances from the outer aspect of the zygomatic arch to the carotid artery (37.5 mm; range: 29-48 mm), internal jugular vein (38.3 mm; range, 31-49 mm), and the third division of the trigeminal nerve (35 mm; 24-46 mm) were greater than that of the middle meningeal artery, but are nevertheless at risk for injury during TMJ surgery.
Reference:
Talebzadeh, N. Rosenstein, TP. Pogrel, MA. Anatomy of the structures medial to the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1999; 88): 674-78.
Patients who undergo unilateral segmental mandibular resection with preservation of a short condylar segment can be expected to have what findings prior to delayed mandibular reconstruction:
A. painful disc displacement with the condyle out of the fossa.
B. painless normal disc relationship with the condyle in the fossa.
C. painless disc displacement with the condyle out of the fossa.
D. painless normal disc relationship with the condyle out of the fossa.
Answer: D
Rationale:
Unilateral segmental mandibular resection does not affect the relationship between the disc and the condyle. Most condyles with a short condyle-ramus remnant will displace out of the fossa while retaining a normal relationship to the disc. Clinical symptoms of TMJ pain, TMJ noise, or muscular pain are not associated with partial mandibulectomy defects.
Reference:
Yoshiki H, Toshirou K, Kazutoshi N, Kanichi S: Magnetic resonance imaging findings and clinical symptoms in the temporomandibular joint in patients with mandibular continuity defects. J Oral and Maxillofac Surg 2000;50: 487-493.
A TMJ MRI has been obtained on a symptomatic 19-year-old. Which clinical scenario is most compatible with this imaging study? (MRI shows unilateral disk displacement without reduction)
A. Bilateral clicking
B. Recent cessation of clicking with deviation on opening C. Unilateral reciprocal clicking
D. Bilateral crepitace
Answer: B
Rationale:
This MRI demonstrates unilateral disc displacement without reduction. Preservation of near normal disc morphology is consistent with recent progression to disc displacement without reduction. The contralateral joint disc position is normal. No clicking would be expected and, in fact, this patient stopped clicking and experienced a closed lock with deviation to the locked side 3 weeks prior to the MRI. The MRI demonstrates normal condylar morphology without evidence of arthrosis.
Reference:
Katzberg RW, et al. Magnetic resonance imaging of the temporomandibular joint meniscus. Ora Surg Oral Med Oral Pathol 1985;59:332.
Anderson QN. Temporomandibular joint imaging: treatment planning. In: Fonseca RJ, Bays RA, Quinn PD (eds):Oral and Maxillofacial Surgery Vol 4. 2000, WB Saunders, Philadelphia, pp129-142.
A 12 year-old male is noted to have his mandibular dental and symphysis midlines 3 mm to the right of his facial midline. Centric occlusion position approximates centric relation position. These findings are most consistent with:
A. myofascial pain dysfunction.
B. internal derangement of the right TMJ.
C. left lateral pterygoid spasm.
D. internal derangement of the left TMJ.
Answer: B
Rationale:
Mandibular asymmetry in a growing child is often associated with an internal derangement on the short side. This association is associated with a small or deformed condyle and decreased vertical ramus height on the affected side.
Reference:
Schellhas KP, Pollei SR, Wilkes CH: Pediatric Internal Derangements of the Temporomandibular Joint: Effect on facial development. Am J Orthodont Dentofac Orthoped, 1993;104:51-59
What is the most common configuration of TMJ disc displacement? A. Medial B. Anteromedial C. Anterior D. Anterolateral
Answer: C
Rationale:
Of 58 consecutive TMJ patients imaged by 3-DIMENSIONal MRI 44/116 (38%) had anterior displacement of the TMJ disk. 23/116 (20%) had anterolateral displacement, 10/116 (9%) had medial displacement, and 10/116 (9%) had anteromedial displacement.
Reference:
Simmons HC, Gibbs SJ: Initial TMJ disk recapture with anterior repositioning appliances and relation to dental history. J Craniomandib Prac 1997;15:281-295.
Which of the following skeletal jaw deformities is most likely associated with long- standing bilateral TMJ disc displacement without reduction?
A. High mandibular plane angle Class II malocclusion
B. Asymmetric Class II malocclusion
C. Low mandibular plane angle Class II malocclusion D. Class III malocclusion
Answer: A
Rationale:
TMJ internal derangement should be suspected in patients with mandibular deficiency, symmetrical and asymmetric Class II malocclusion, and vertical ramus deficiency with anterior open bite. Of the skeletal deformity options, high mandibular plane angle Class II patient is most likely to be associated with bilateral non-reducing disc displacements. Nickerson and Link reported that 11/11 open bite patients and 29/33 Class II patients had bilateral internal derangements.
Reference:
Link JL, Nickerson JW. Temporomandibular joint internal derangements in an orthognathic surgery population. Int J Adult Orthod Orthognath Surg 1992;7:161-9 Gidarakou IK, Tallents RH, Kyrkanides S, et al. Comparison of skeletal and dental morphology in asymptomatic volunteers and symptomatic patients with bilateral disc displacement with reduction. Angle Orthod 2002;72:541-46.
Which of the following is the most common complaint in TMD patients? A. Pain with opening
B. Open lock C. Headache D. Tinnitus
Answer: C
Rationale:
Forty-eight consecutive TMD patients were asked 86 different symptoms on initial diagnostic visit. The occurrence of the symptoms was: Cephalalgia 94%, Painful to chew food 94%, Pain upon opening or closing mouth 90%, Open lock 13%.
Reference:
Simmons HC, Gibbs SJ: Anterior Repositioning Appliance Therapy for TMJ Disorders: Specific symptoms relieved and relationship to disk status on MRI. J Craniomandib Prac 2005;23:89-99
Which of the following devices is an absolute contraindication to performing an MRI of the temporomandibular joint? A. Cardiac pacemaker B. Titanium dental implants C. Orthodontic appliances D. Prosthetic knee joint
Answer: A
Rationale:
A cardiac pacemaker can malfunction when subjected to a strong magnetic field. The other choices are typically not affected by the magnetic field.
Reference:
Quinn, P: Color Atlas of Temporomandibular Joint Surgery, St. Louis, 1998, Mosby, p. 23.
What tissue type demonstrates a bright signal on T1-weighted MR images? A. Fat B. Muscle C. Bone D. Cartilage
Answer: A
Rationale:
Fat appears as a bright (white) signal on conventional T1 weighted MRI.
Reference:
Cunningham, L et al. Magnetic resonance imaging of the head and neck. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 2003;11:87-88.
A 21 year-old patient with a two week history of painful limited opening (20 mm interincisal) presents with the following MRI images. What is the most likely diagnosis? A. Acute TM joint effusion B. Disc displacement without reduction C. Disc displacement with reduction D. Lateral pterygoid fibrosis
Rationale:
C. The question presents a patient with acute onset of hypomobility. T1 weighted MRI images in closed and open mouth views are presented. The disc is displaced in the closed mouth view, and does not reduce in the open mouth image. Muscle fibrosis would not occur acutely. Joint effusion is best imaged with a T2 weighted MRI.
Reference:
Katzberg, RW. Temporomandibular joint imaging. Radiology 1989;170:297-307 Manzione, JV, Katzberg, RW, Tallents, RH. Magnetic resonance imaging of the temporomandibular joint. J Am Dent Assoc 1986;113:398-402.
Which statement is true regarding TMJ magnetic resonance imaging technique?
A. Sagittal images should be parallel to the long axis of the condyle
B. Coronal images should be perpendicular to the long axis of the condyle
C. Image should be acquired with surface coils
D. Open mouth images should be acquired at an opening that does not produce an opening click
Answer: C
Rationale:
MRI of the TMJ image slice thickness should never be more than 3 mm. Sagittal images should be perpendicular and coronal images parallel to the condylar long axis. Open mouth images should be acquired at an opening that produces an opening click as this click may represent a reducing disc.
Reference:
Gibbs SJ, Simmons HC: A protocol for magnetic resonance imaging of the temporomandibular joint. J Craniomandib Prac 1998 16:236-241.
A T2 weighted image of the temporomandibular joint best demonstrates which of the following joint abnormalities?
A. Superior joint space adhesions
B. Perforation of the Temporomandibular Disc
C. Arthrosis of the bony condyle
D. Joint effusion
Answer: D
Rationale:
T2 weighted images best demonstrate structures with high water content. Joint effusion is best demonstrated by this modality.
Reference:
Quinn, P: Color Atlas of Temporomandibular Joint Surgery, St. Louis, 1998, Mosby, p. 22.
What statement best describes a Wilkes Stage III TMJ internal derangement?
A. Non-reducing disk displacement-chronic
B. Non-reducing disk displacement-subacute/acute
C. Reducing disk displacement-chronic
D. Reducing disk displacement-subacute/acute
Answer: B
Rationale:
In the Wilkes Classification of internal derangement stage III represents a non-reducing disk displacement that is acute or subacute. Early stage III internal derangements may be reducible with mandibular manipulation. Late stage III internal derangements represent permanent disc displacement.
Reference:
Bays, R: Surgery for Internal Derangement. In Fonseca, R (ed): Oral and Maxillofacial Surgery, Vol. 4. Philadelphia, WB Saunders, 2000, p 276.
Which of the following is consistent with Wilkes Stage III internal derangement?
A. Painless reducing disc
B. Painless nonreducing perforated disc
C. Painful reducing disc
D. Acute or subacute painful nonreducing disc
Answer: D
Rationale:
Stage III refers to disc displacement without reduction often associated with pain but prior to any hard tissue changes.
A. Describes Stage I B. Describes Stage V C. Describes Stage II
Reference:
Bays RA :Surgery for Internal Derangement. In Fonseca RJ, Bays RA, Quinn PD (eds):Oral and Maxillofacial Surgery Vol 4. 2000, WB Saunders, Philadelphia ,p. 276.
What results are expected 6 months after TMJ arthrocentesis for pain and limitation of motion from osteoarthritis?
A. Increased range of motion and decreased pain
B. Unchanged range of motion and decreased pain
C. Increased range of motion and unchanged pain
D. Decreased range of motion and decreased pain
Answer: A
Rationale:
Arthrocentesis is a safe procedure that in many instances results in the osteoarthritic TMJs returning to a healthy functional state. Failure of arthrocentesis suggests that the painful limitation is most probably caused by changes such as fibrous adhesions or osteophytes that require surgical intervention for their removal. Of 38 TMJs treated with arthrocentesis, 26 joints responded favorably; pain and dysfunction scores were reduced from 9.86 ± 0.73 to 3.39 ± 0.76 and from 11.34 ± 0.66 to 3.4 ± 0.69, respectively (P
Regarding TMJ discectomy and dermal graft placement, which of the following is most correct?
A. With joint function, dermis assumes a biconcave shape.
B. Dermis grafting prevents condylar erosion after discectomy.
C. Dermis grafting has not been demonstrated superior to discectomy alone. D. Dermis grafting limits intraarticular adhesion formation.
Answer: C
Rationale:
There is little evidence that dermal graft placement produces results superior to discectomy, alone. Dermis does not assume a biconcave shape and does not prevent condylar erosion after discectomy. Dermal grafting does no prevent intraarticular adhesion formation.
Reference:
Bays RA :Surgery for Internal Derangement. In Fonseca RJ, Bays RA, Quinn PD (eds):Oral and Maxillofacial Surgery Temporomandibular Disorders. Philadelphia, WB Saunders, 2000 , Volume 4, p 292.
The expected outcome after unilateral temporomandibular joint discectomy without disc replacement is: A. open bite. B. loss of range of motion. C. subcondylar cyst formation. D. formation of a pseudo-disc.
Answer: D
Rationale:
MR imaging after discectomy without disc replacement has demonstrated formation of new tissue between the condyle and fossa. This tissue has been referred to as pseudo- disc because of its location. Loss of mandibular height, open bite, crepitation, loss of range of motion, though described in isolated cases, are not the usual outcome of discectomy. Accelerated condylar arthrosis has also been observed but with avoidance of early joint loading is not expected. Subcondylar cyst formation is a manifestation of osteoarthritis and not associated with discectomy.
Reference:
Susumu T, Tsuguo S, Masashi Y: Long-term magnetic resonance imaging after temporomandibular joint discectomy without replacement. J Oral Maxillofac Surg 2000;58:739-745.
To protect the facial nerve in the pre auricular approach to the temporomandibular joint, the incision through the fascia and periosteum in the area of the zygomatic arch should not be more than ________ cm from the anterior border of the external auditory canal.
A. .8 cm B. .5cm C. 1.5cm D. 2.2cm
Answer: A
Rationale:
The facial nerve crosses the zygomatic arch .8cm to 3.5cm anterior to the anterior border of the external auditory canal. Therefore, the incision through temporoparietal fascia and periosteum should not be more than be .8cm anterior to the anterior border of the external auditory canal.
Reference:
Ellis, E, Zide, M: Surgical Approaches to the Facial Skeleton, Baltimore, 1995, Williams and Wilkins, p. 165.
Condylotomy for symptomatic internal derangement has the greatest positive clinical effect with regard to improvement in:
A. pre-existing malocclusion.
B. position of a non-reducing disc.
C. symptoms associated with Wilkes stage II and III internal derangement. D. symptoms associated with Wilkes stage IV and V internal derangement.
Answer: C
Rationale:
Pain and diet are significantly improved 3 years after modified condylotomy for internal derangement. Disc position is improved at least 70% of the time with disc displacement with reduction. Non-reducing disc displacement is unaffected by condylotomy. Late stage internal derangement joints with degenerative joint disease (Wilkes Stage IV, V) have less satisfactory pain relief after modified condylotomy. Although modified condylotomy can be applied simultaneously to the patient with Class III malocclusion and symptomatic internal derangement this is not well documented and a represents a more novel application of condylotomy.
Reference:
Hall HD, Navarro ZE, Gibbs SJ: Prospective study of modified condylotomy for treatment of nonreducing disc displacement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:147-158.
Hall HD, Navarro ZE, Gibbs SJ: One- and three-year prospective outcome study of modified condylotomy for treatment of reducing disc displacement. J Oral Maxillofac Surg 2000;58:7-17.
Compared to no disc replacement, the main advantage of placing a dermis graft in conjunction with TMJ discectomy is:
A. enhanced pain relief.
B. improved range of motion.
C. decreased joint noise.
D. decreased regressive condylar remodeling.
Answer: C
Rationale:
Interpositional dermis can decrease joint noise after discectomy. No clinical evidence of joint sounds such as crepitus was found in 33 of 35 operated joints evaluated an average of 2 years after discectomy with placement of a dermis interpositional graft. Dermis grafting has no effect on pain response, range of motion or the incidence of regressive condylar remodeling following discectomy.
Reference:
Dimitrioulis G: The use of dermis grafts after discectomy for internal derangement of the temporomandibular joint JOMS. J. Oral Maxillofac Surg 2005;63:75
Which branch of cranial nerve VII is at greatest risk with the pre-auricular approach to the temporomandibular joint? A. Buccal B. Zygomatic C. Cervical D. Temporal
Answer: D
Rationale:
The most commonly injured branch of the facial nerve is the temporal branch with preauricular approach to the TMJ. Less commonly, the zygomatic branch may be injured.
Reference:
Vallerand WP, Dolwick MF. Complication of temporomandibular joint surgery. Oral Maxillofac Clin North Am 1990;2:481-8.
What statement describes a functional deficit associated with injury to the frontal branch of the facial nerve? A. Lagophthalmos B. Exposure keratitis C. Brow ptosis D. Hypertropia
Answer: C
Rationale:
Injury to the frontal branch of the facial nerve causes frontalis weakness and brow ptosis. Lagophthalmos and exposure keratitis are associated with injury to the zygomatic branch of the facial nerve. Hypertropia refers to globe elevation from impaired globe depressor function, as may be seen in injury to the inferior division of the oculomotor nerve.
Reference:
Quinn P: Color atlas of temporomandibular joint surgery; 1998 Mosby St. Louis p.31
During intra-articular TMJ surgery, preservation of the medial capsule, may avoid damage to which vascular structure? A. The internal maxillary artery B. The masseteric artery C. The deep temporal artery D. The middle meningeal artery
Answer: D
Rationale:
The middle meningeal artery is immediately medial to the temporomandibular joint. Preservation of the medial joint capsule will minimize injury to this vascular structure. Options a,b,c, are incorrect because none of these vessels course immediately adjacent to the medial portion of the TMJ.
Reference:
Mohamed,S:Developmental and Clinical Anatomy and Physiology of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn PD (eds):Oral and Maxillofacial Surgery Vol 4, 2000 WB Saunders, Philadelphia, p 4.
Compared to discectomy, a more common complication of modified mandibular condylotomy is? A. Change in occlusion B. Post operative joint noise C. Intraarticular adhesions D. Condylar arthrosis
Answer: A
Rationale:
Condylar “sag” and loss of ramus height can lead to a posterior occlusal prematurity on the side of a modified condylotomy. Occlusion changes following discectomy, if any, are mild and transient. Joint noise is more common after discectomy because of intraarticular scarring/adhesions.
Reference:
Bays RA :Surgery for Internal Derangement. In Fonseca RJ, Bays RA, Quinn PD (eds): Oral and Maxillofacial Surgery Vol 4, 2000, WB Saunders, Philadelphia, p. 297.
During TMJ arthrotomy, what structure is most likely to be the source of bleeding during entry into the superior joint space?
A. Superior head of the lateral pterygoid muscle
B. Inferior head of the lateral pterygoid muscle
C. Retrodiscal tissue
D. Posterior temporalis muscle
Answer: C
Rationale:
The retrodiscal tissue has a robust blood supply and can be encountered as the lateral capsule is incised and the joint space entered.
a. and b. are incorrect because they are encountered at the very anterior and medial region of the joint.
d. is incorrect because it is usually encountered before the joint capsule has been opened.
Reference:
Mohamed,S:Developmental and Clinical Anatomy and Physiology of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn PD (eds):Oral and Maxillofacial Surgery Vol 4 2000 WB Saunders, Philadelphia, p 6.
During modified mandibular condylotomy surgery what is the maximum distance that the oscillating blade must extend medially beyond ramus at the level of the midsigmoid notch to place the internal maxillary artery at least risk of injury? A. 20 mm B. 15 mm C. 10 mm D. 5
Answer: D
Rationale:
The mean distance from the internal maxillary artery to the midsigmoid ramus is only 3.3 mm. In addition to the risk of injury to the internal maxillary artery, a branch of the internal maxillary artery, the masseteric artery, passes through the sigmoid notch to supply the masseter muscle. Both arteries are at risk during modified condylotomy.
Reference:
Fujimura K, Segami N, Kobayashi S. Anatomical study of the complications of intraoral vertico-sagittal ramus osteotomy. J Oral Maxillofac Surg 64:384-389, 2006
The surface of the mandibular condyle is covered with what material? A. Hyaline cartilage B. Synovium C. Fibrous connective tissue D. Fibrocartilage
Answer: D
Rationale:
The TMJ articular surface of the condyle covered with fibrocartilage.
best suited to loading of the articular surface, while also allowing remodeling. A, B, and C do not form the covering of the condyle.
Reference:
Mohamed, S: Developmental and Clinical Anatomy and Physiology of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn PD (eds): Oral and Maxillofacial Surgery. Vol 4, 2000, WB Saunders, Philadelphia, p 8.
