Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Oral Board Flashcards > TMJ/Facial Pain > Flashcards

TMJ/Facial Pain Flashcards

1
Q

What are extra-articular disorders?

A

-Makes up majority of TMJ complaints (95%)
-Hand to side of the face
-Can range from muscular pain to other conditions that present as TMJ pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are causes of muscle pain?

A

-Muscle fatigue
-Heavy exercise
-Dehydration
-Pregnancy
-Hypothyroidism
-Decreased Mg or Ca
-ETOH abuse
-Renal failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is Hilton’s orthopedic law?

A

The nerves that innervate a joint, also innervate the muscles that move the joint along with overlying skin

TMJ- CN V

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are conditions that can mimic extra-articular pain?

A

Pulpitis, pericoronitis, otitis, sinusitis, parotitis, trigeminal neuralgia, atypical facial pain, temporal arteritis, nasopharyngeal Ca, Eagle’ssyndrome/fractured styloid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are extra-articular conditions that cause limited jaw function?

A

-Odontogenic/non-odontogenic infections
-myositis/myofacitis
-myositis ossifacans
-neoplasms
-scleroderma
-coronoid hyperplasia
-zygomatic arch fractures
-psychological (hysteria, extra pyramidal reactions)
-tetanus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe the facial pain cycle.

A

-Predisposed susceptible muscle group
-Precipitating traumatic event
-Perpetuating para-functional habit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the management for extra-articular disorders?

A

Non-invasive measures:
-Jaw rest
-Soft diet
-Stretch/PT
-Ice/moist heat
-Orthotic splint
-Amitriptyline10-30 mg at bedtime to prevent bruxism
-NSAIDs (mobic 7.5 mg per day)
-Behavioral counseling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are intra-articular disorders?

A

Less common ~5%, finger pointing directly to joint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are developmental causes of intra-articular disorders?

A

Condylar hyperplasia, condylar hypoplasia

-Tx with reestablishment of occlusion, reconstruction with orthognathic surgery, costochondral graft, custom alloplastic implant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are neoplastic causes of intra-articular disorders?

A

Benign: Osteoma, synovial chrodomatosis, osteochondroma

Malignant: Fibrosarcoma, osteosarcoma, synovial sarcoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are traumatic causes of intra-articular disorders?

A

Subluxation, dislocation, fracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe arthritic intra-articular disorder.

A

-Pathogenesis for degenerative changes of articular cartilage
-Stress from bruxism
-chronic microtrauma
-Compression and shearing
-Chondrocyte damage (collaganases)
-Proteoglycan chain splitting and water loss
-Loss of cartilage resilience
-Chondromalacia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe the imaging for TMJ evaluation.

A

Panorex: Initial screening
CT: Bony pathology
MRI: Soft tissue, disc position

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe MRI TMJ imaging.

A

T1: Bright: Fat, bone marrow, better for anatomy
T2: Bright: Water/edema, better for anatomy

-Earliest findings of internal derangement is T2 hyper-intensity in the bilaminar zone
-Late stage: T2 disc deformity (biconvex, thickened, folded, perforation)

-Anterior or anteriolateral disc displacement is most common finding

-With progression of disease, disc does not reduce, becomes fixed anteriorly during opening/closing

-Fluid accumulates in joint

-Cortical erosion with condylar head flattening and anterior osteophytes
-Subchondral marrow edema followed by low signal sclerosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Describe Wilkes Stage I

A

Early Stage
-Clinical: No significnt mechanical symptmos other than early opening reciprocal click, no pain or limited ROM
-Radiographic: Slight forward displacement, good contour of disc
-Anatomic: Excellent for slight anterior displacement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Describe Wilkes Stage II

A

Early/Intermediate Stage
-Clinical: One or more episodes of pain, beginning major mechanical problems, mid to late opening loud click, transient catching/locking
-Radiographic: Slight forward displacement, beginning disc deformity with slight thickening
-Anatomic: Anterior disc displacement, disc deformity with good central articulating area

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Describe Wilkes Stage III

A

Intermediate Stage
-Clinical: Multiple episodes of pain with restriction of function, major mechanical symptoms with locking
-Radiographic: Anterior disc displacement with significant deformity/prolapse
-Anatomic: Marked anatomic disc deformity with anterior displacement, no hard tissue change

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe Wilkes Stage IV

A

Intermediate/Late Stage
-Clinical: Slight increase in severity over intermediate
-Radiographic: Increase in severity showing early degenerative changes, deformed condylar head, sclerosis
-Anatomic: Hard tissue degenerative remodeling with osteophytes, adhesions in anterior and posterior recess, no perforation of disc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Describe Wilkes Stage V

A

Late stage
-Clinical: Crepitus, grating, grinding, continual pain, chronic restriction of motion, difficult function
-Radiographic: Disc perforation, gross anatomic deformity of disc and hard tissue with degenerative arthritic changes
-Anatomic: Gross degenerative changes of disc and hard tissue, disc perforation, multiple adhesions, osteophytes, flattening of condyle and eminence, subcortical cyst formation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the goals of surgical treatment of the TMJ

A

In patients that have failed non-surgical therapy

Goals: Reduce adverse joint loading, reduce inflammation and pain, establish normal painless ROM

Indications: Significant pain and/or dysfunction when non-surgical therapy has failed, evidence of disease on imaging, localized pain to the joint the better the prognosis (more diffuse pain=worse prognosis), failure to manage associated myofascial pain and dysfunction will worsen the surgical success rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the indications/contraindications to arthrocentesis?

A

Indications: TMJ arthralgia, ADD with reduction/pain, ADD w/o reduction chronic or acute, previously operated joints without pain relief

Contraindications: Severe limited opening, bony or fibrous ankylosis

22
Q

Describe your arthrocentesis procedure.

A

-Double vs double lavage port (double)
-10-2 point, 10 mm and 2 mm inferior to canthal-tragal line
-Second port is 10 mm anterior to posterior port
-Lavage joint, break adhesions with hydraulic pressure, 100 ml LR
-Steroid in joint

-Advantages: Minimally invasive, office procedure with IVS, easy technique, similar (70-95%) success rate as arthroscopy
-Disadvantages: Cannot visualize joint space or disc

23
Q

Why would you choose an arthroscopy instead of an arthrocentesis?

A

-Painful, limited opening refractory to arthrocentesis
-Need to visualize joint

24
Q

Describe your arthroscopy technique?

A

-Dual port techniques (can do single vs triple as well)
-Do with GA also IVS with 0.7 mm scope

-10-2 point (10 mm and 2 mm inferior to canthal-tragal line)
-Distend joint, skin punctured with sharp trocar
-Switch to blunt/camera
-Approach superior posterolateral (trochar angled anterior and medial)
-Second port 10 mm anterior
-Sweep joint to break adhesions
-Lavage
-Steroid
-Important post-op aggressive PT, NSAIDs, splint, soft diet

Success rate is 80% (better for Wilkes 2-3)

25
Q

How is synovitis and chondromalacia graded in an arthroscopy?

A

Synovitis Acute index:
-Type 1: Minimal vasodilation, no hyperemia
-Type 2: Moderate vasodilation, early hyperemia
-Type 3: Considerable vasodilation, moderate hyperemia
-Type 4: Total hyperemia, completely obliterates vascular patterns

Grading of chondromalacia
-Grade I: Softening of cartilage
-Grade II: Furrowing
-Grade III: Fibrillation and ulceration
-Grade IV: Crater formation and subchondral bone exposure

26
Q

What are potential complications of arthrocentesis?

A

-Neurologic (CN V transient hypoesthesia usually self resolving within 6 mo)
-CN VII very rare (tx with artificial tears, eye patch, PT)
-Middle cranial fossa violation (NSGY consult, hospitalization)
-Vascular (Usually stops on own, may add vasoconstrictor, pressure dressing)
-Bleeding on initial entry due to superficial temporal artery/vein, transverse artery, masseteric artery, tx with pressure, may need to ligate
-Severe bleeding deep from condyle may be from I max, require open tx or embolization
-Otologic: laceration of EOC treat with obs and antibiotic drops
-Broken instrument: Attempt retrieval. May need to open joint
-Infection: Very rare, tx with cephalosporin

27
Q

What are the indications of arthrotomy?

A

-Failed previous surgery with continued problems
-Mechanical interferences (intermitent locking, dysfunctional click)

28
Q

What is the rationale of arthroplasty with disc preservation?

A

-Disease process may be reversed by normalization of the disc and eliminating function on posterior attachment and retrodiscal tissue will remove source of inflammation (improves articular cartilage nutrition and lubrication)

29
Q

What are the approahces to arthroplasty with disc preservation?

A

-Pre-auricular, endaural, post-auricular

30
Q

What are the requirements of the disc for disc preservation?

A

-Minimal disc displacement
-Disc is near normal length
-Disc is near normal shape (bowtie)

31
Q

Describe the pre-auricular approach and surgery for arthroplasty with disc preservation.

A
  • 3-4 cm incision in preauricular skin crease with slight 1-2 cm superior curve, inferior aspect does not go below lobule of ear

-Dissect through skin and subQ tissue to depth of temporalis fascia (glistening white)

-Zygomatic arch and lateral pole of condyle palpated

-Oblique incision parallel to frontal branch of facial nerve through the superficial layer of the temporalis fascia above zygomatic arch

-Dissection with periosteal elevator beneath superifical layer of temporalis fascia to strip periosteum off lateral zygomatic arch

-Horizontal incision just below the lateral rim of the glenoid fossa will expose superior joint space, dissection continued inferiorly removing attachment of capsule of disc (expose inferior joint space)

-Disc freed up, retrodiscal tissue remove, disc is plicated back into position, may reduce portion of eminence to aid dissection of disc

-Capsule closed, deeps, then skin closed

32
Q

What is your post-op care after arthroplasty with disc preservation?

A

Aggressive PWT< NSAIDs, reduce joint loading with splint, medications for bruxism, soft diet x3 months

33
Q

What is the long term success of arthroplasty with disc preservation?

A

80%

34
Q

What are potential complications of arthoplasty with disc preservation?

A

-Limited opening due to fibrous adhesions
-Continued pain or dysfunction
-Facial nerve deficit
-Bleeding

35
Q

Where is potential bleeding from arthroplasty?

A

-If posterior to condyle due to retrodiscal tissues, use of specialized right angled clamps during resection of tissue then cauterize

-If medial and deep to condyle then branch off IMAX, may control with packing/local, may require embolization

36
Q

When is arthroplasty with disc removal preformed?

A

Same as disc preservation when disc cannot be saved (deformity of perforation)

37
Q

What are the differences in the procedure?

A

-Partial/full removal of disc
-Preserve synovium (provides nutrition and lubrication of articular surfaces)
-Consider interpositional graft (temporalis fascia, postauricular cartilage, dermis or fat)

-Success rate the same: 80%

-Will have significant TMJ remodeling and crepitus

38
Q

What are complications of arthroplasty with disc removal?

A

-Severe condylar resorption
-Malocclusion
-Heterotropic bone formation with ankylosis
-Continued pain and or dysfunction

39
Q

What is a condylotomy?

A

Basically an IVRO

40
Q

What is the procedure of a condylotomy?

A

-Arch bars
-Expose ramus
-Bauer retractor placed in sigmoid notch
-Vertical ramus osteotomy 7 mm from posterior border
-Strip 1/3 of medial pteygoid muscle to allow 2-3 mm of condylar sag
-Place in MMF
-Close incision

-1 week MMF for unilateral, 3 weeks for bilateral. Elastics up to 6 weeks but mauy need longer

41
Q

What are the indications for a TJR?

A

End stage disease

-Failed previous surgeries
-Degenerative OA/RA
-Loss of vertical mandibular height and occlusal relationship secondary to condylar resorption, trauma, pathology or developmental deformity
-Avascular necrosis
-Ankylosis (bony or fibrous)
-Not for chronic pain only

42
Q

What are the contraindications to TJR?

A

-Active infection, inadequate bone support, skeletally immature patient

43
Q

What are the two types of TJR?

A

-TMJ concepts custom joint
-Biomet stock with multiple sizes

44
Q

What is the technique of TJR?

A

-Retromandibular and preauricular approach

-Create gap and coronoidectomy

-Place pt in MMF

-Place fossa/condylar implant

-Check occlusion/ROM

-Secure implant, consider fat graft

-Close incision

45
Q

What is your post-op care for a TJR?

A

-Post op elastics 3-5 days

-Aggressive PT, antibiotics

46
Q

What are complications from TJR?

A

-Facial nerve injury
-Chronic pain
-Loss of function
-Malocclusion
-Infection
-Hardware loosening
-Hearing complaints
-Heterotropic bone formation
-Foreign body or allergic reaction

47
Q

Describe TMJ ankylosis.

A

-Extra-articular (pseudo) or intra-articular (true)
-Mandibular hypomobility
-May not be painful
-May be hard tissue or soft tissue

48
Q

What are potential causes of TMJ ankylosis?

A

-Trauma (intracapsular condylar fractures)
-Multiple TMJ surgeries
-Systemic (ankylosing spondylitis, rheumatoid arthritis)
-Infectious (mastoiditis, ottitis media
-Neoplasm (osteoma, osteochondroma)

49
Q

What are clinical signs of TMJ ankylosis?

A

-Limited ROM
-Airway issues
-Diet only soft/inadequate
-Limited dental care
-Facial asymmetry w/wo retrognathia

50
Q

What are treatments for TMJ ankylosis?

A

-Typically require surgical intervention

-Aggressive and extended post-surgical PT
-COnsider low dose radiaiton- day 4, 20 Gy in 10 fractions
-Coronoidectomy
-NSAIDs
-May require TJR in adults or costochondral graft in child

51
Q

Describe your technique for a costochondral graft?

A

-Harvest contralateral 5-7 rib
-Harvest 7-10cm with 1 cm of cartilage
-Contour cartilage to <5 mm leaving costochondral junction
-Contour rib to ramus, fixate with screws/wires
-MMF 2-4 weeks
-Soft diet 6 months
-Gentle ROM exercises
-Control loading joint

52
Q

What are complications with costochondral graft?

A

-Pneumothorax-Tx locally with red rubber catheter
-Resorption of rib
-Ankylosis-may need radiation tx
-Limited function w/o translation, limited excursive movements
-Variable growth

Oral Board Flashcards (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions