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TMJ > Internal Derangement of TMJ,ankylosis, > Flashcards

Internal Derangement of TMJ,ankylosis, Flashcards

1
Q

define internal derangement of TMJ

A

disorder of TMJ in which articular disk is in an abnormal position as it relates to the condyle and fossa when the teeth are in occlusion.

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2
Q

what can malposition of the articular disk lead to? (4)

A

-pain
-instability
-dec range of motion
-abnormal mobility of mandible

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3
Q

6 etiologies of internal derangement of TMJ

A

-trauma
-joint laxity
-parafunctional habits
-altered joint lubrication system
-anchored disk phenomenon (disk adhesion to articular fossa)
-myofascial pain dysfunction

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4
Q

-dec max incisal opening
-deviation
-deflection
-palpable clicks (reciprocal)
-crepitus
-patients complain of pain in preauricular region

A

internal derangement of the TMJ

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5
Q

Imaging dx for internal derangemeent of TMJ

A

MRI-T1 and T2. Disk is normally displaced in an anteriomedial vector
-osseous changes
-abnormal contours of disk

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5
Q

disk displacement w/o reduction

A

patient attempts to open but condyle can’t pass over posterior band of disk.

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6
Q

what do you see with disk displacement w/o reduction

A

deflection to the ipsilateral side
decreased excursion to contralateral side

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6
Q

what is disk displacement w/ reduction when patient opens what happens?

A

patient opens mouth w/ click that is produced when condyle passes over posterior part of disk
-during opening the disk returns to normal anatomical position
-during closing , a second click can be appreciated as the condyle passes back over the thickened posterior portion of the disk.

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7
Q

what classification classifies the degree of internal derangement and provides guidance in treatment options?

A

Wilkes classification
stage I-V

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8
Q

Wilkes stage 1 radiographic findings

A

anterior disk displacement
normal disk contour, no osseous changes

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8
Q

Wilkes stage 1 clinical findings

A

painless clicking
no pain
no locking

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9
Q

Wilkes stage 1 surgical findings

A

normal disk noted and displaced anteromedially

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10
Q

Wilkes stage II clinical findings

A

occasional painful clicking with intermittent locking

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11
Q

wilkes stage II radiographic findings

A

anterior disk displacement w/reduction on opening
mild disk deformity w/ no osseous changes

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12
Q

wilkes stage II surgical findings

A

disk thickened and displaced anteriormedially

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13
Q

wilkes stage III clinical findings

A

-frequent painful clicking w/ severe limitation in range of motion
-joint tenderness

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14
Q

wilkes stage III radiographic findings

A

anterior disk displacement w/o reduction
moderate disk deformity
no osseous changes

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15
Q

wilkes stage III surgical findings

A

deformed disk and displaced anteromedially
-adhesions may be appreciated

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16
Q

wilkes stage IV clinical findings

A

-restricted range of motion with chronic pain and joint crepitus

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17
Q

wilkes stage IV radiographic findings

A

anterior disk displacement w/o reduction
marked disk deformity w/ osseous changes

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18
Q

wilkes stage IV surgical findings

A

disk perforated w/ osseous changings of the condylar head and fossa

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19
Q

wilkes stage V clinical findings

A

joint pain and crepitus

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20
Q

wilkes stage V radiographic findings

A

disk displaced
marked disk deformity w/ severe osseous changes

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21
Q

wilkes stage V surgical findings

A

disk perforated w/ severe osseous changes of the condylar head and fossa.

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22
Q

6 tx of internal derangement of TMJ

A

-conservative tx
-intra-articular injections w/ local anesthetic/steroid mixture
-arthrocentesis w/ or w/o arthroscopy w/ repositioning
-meniscectomy w/ or w/o graft replacement
-modified condylectomoy
-post op physical therapy

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23
Q

2 classification systems of ankylosis

A

Sawhney Type 1-4
Topazian stage 1-3

24
Q

Topazian stages

A

stage 1-only condyle
stage 2-extends to sigmoid notch
stage 3-entire condyle,sigmoid notch and coronoid

25
Q

sawhney type 1 and type 2

A

type 1-flattned condylar head w/ close approximation to joint space
type 2-flattened condyle close to glenoid fossa,bony fusion on outer surface of articular surface. No fusion of medial joint space

26
Q

sawhney type 3 and 4

A

type 3-bony block bridging the mandibular ramus and zygomatic arch
type4-wider boney block bridges the mandibular ramus and zygomatic arch, completely replacing architecture of joint

27
Q

adult tx of tmj ankylosis

A

prosthetic joint

28
Q

pediatric tx of tmj ankylosis

A

7 step KABAN protocol

29
Q

7 step Kaban protocol

A

1.aggressive resection of fibrous/bony ankylotic mass
2.coronoidectomy on affected side and measure intra op MIO
3.coronoidectomy on contralateral side if can’t achieve MIO>35 mm and/or to the point of dislocation of the unaffected TMJ
4.Lining of the TMJ w/ temporalis myofascial flap or disk if salvageable
5.reconstruction of ramus condyle unit
6.early mobilization of jaw
7.aggressive physiotherapy

30
Q

2 ways to reconstruct ramus condyle unit

A

-distraction osteogenesis
-costochondral graft

31
Q

reconstruction of ramus condyle unit with distraction osteogenesis, when do you activate?
when do you mobilize?

A

activate in 2-4 days
mobilize day of operation

32
Q

reconstruction of ramus condyle unit with costochondral graft, how long do you put in maxillary-mandibular fixation?
when do you mobilize?

A

10 days IMF
mobilize after 10 days of IMF

33
Q

what takes advantage of the fibrocartilaginous cap that forms on the advancing front of the distracted bone heading toward the fossa

A

distraction osteogenesis

34
Q

2 tx for fibrous ankylosis

A

-lysis of adhesions and fibrosis
-diskectomy

35
Q

post op radiation tx for ankylosis

A

radiation therapy, 20 Gray in 10 fractions to prevent recurrence and consider when using autogenous grafting as the risk of recurrence is higher

36
Q

how much rib can be harvested from child

A

7-10 cm

37
Q

how much rib can be harvested from adult

A

12-17 cm

38
Q

which ribs can be harvested and why

A

ribs 4-7 bc they have direct cartilaginous connection to the strernum.

39
Q

what rib is mostly harvested and why?

A

rib 6, as incision falls in the inframmamary crease creating a better cosmetic outcome

40
Q

which side of rib to harvest?

A

right side- less confusion w/ cardiogenic pain
-contralateral to side of defect to allow appropriate curvature.

41
Q

rib harvest, describe incision

A

sharp incision inframammary crease 5 cm long

42
Q

dissection of rib harvest is

A

subcutaneous tissue
fascia
plane btwn pec major and rectus abdominis

43
Q

what is used to straddle the 5th & 6th intercostal space

A

2 fingers

44
Q

after dissection of
subq tissue
fascia
plane btwn pec major and recutus abdominis what is then done?

A

sharp incision cut through periosteum down to the outer cortex of the rib
-molt periosteal to dissect in subperiosteal plane

45
Q

what is doyen rib stripper associated with

A

pleural tears

46
Q

after you get to subperiosteal plan what do you do?

A

sharp blade to make the cartilagious incision then pull rib laterally and protected rib cutter to section rib

47
Q

why is it impt to not harvest more than 3 cm , no less than 1 cm in children

A

avoid overgrowth of the rib and to prevent seperation of the cartilaginous cap

48
Q

how to check for pleural tears during rib harvest?

A

fill cavity with normal saline and have anesthesia perform valsava to check for bubbles

49
Q

what do you close periosteal sleeve during rib harvest and why

A

3-0 polygalactin, may promote denovo regeneration of the missing rib in the child

50
Q

fascia btwn rectus and pec major is closed with

A

3-0 resorbable suture then close subq and skin.

51
Q

why do you get post op chest x ray after rib harvest?

A

rule out pneumothroax
rule out hemothorax

52
Q

after rib harvest when can patient return to normal activity

A

7 days, strenous activity in 6 weeks.

53
Q

3 complications of rib harvest

A

-cartilaginous cap seperated from harvested rib
-pneumothorax
-pleural tear

54
Q

txcartilaginous cap seperated from harvested rib

A

-drill hole through width or rib and tie nonresorable suture to secure cap
-harvest second rib above, rib directly above is preserved to prevent cosmetic defect.

55
Q

tx
-pneumothorax

A

-10% or less in size can be left to resorb with serial xrays
-100% pneumothorax required needle decompression by placing iv catheter at 2nd intercostal space along mid-clavicular line and listen for rush of air
-tube thoracostomy

56
Q

tx
-pleural tear

A

suction cathether placed in wound, purse string suture through the tear, suction catheter removed under suction while tighteningt he purse string simultaneously

57
Q

tube thoracostomy incision

A

2-3 cm incision at 5th intercostal space
-proximal end of thoracotomy tube is clamped and advanced over 6th rib avoiding neurovascular bundle on inferior border of 5th rib
-tube is placed to water-sealed suction drainage

58
Q

what is it called when condylar head is anterior to the articular eminence causing open lock

A

hypermobility/dislocation/mandibular subluxation resulting in an inability to close from patient’s max incisal open position

59
Q

2 acute tx for dislocation

A

bimanual mandibular manipulation in a downward and posterior vector
wrap head with barton bandadge for a week to allow stretched tissues to heal

60
Q

5 chronic tx for dislocation

A

intra articular injection of sclerosing agent-alcohol or autogenous blood
-botox in lateral pterygoid
-LeClerc/Dautrey procedures-zygomatic arch osteotomites
-eminectomy
-lengthening articular eminence w/ bone graft from calvarium,symphysis,ramus.

TMJ (10 decks)

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