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Flashcards in TMJ/Facial Pain Deck (65)
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1

TMJ Ligaments

  • Attaches medial/lateral, keeps disc/condyle together, 
  • Contains synovial fluid, attaches from neck up to eminence and fossa
  • Inner horizontal part limits posterior movement, outer oblique limits rotation
  • Limits excessive mouth opening

  • Collateral: Attaches medial/lateral, keeps disc/condyle together, 
  • Capsular: Contains synovial fluid, attaches from neck up to eminence and fossa
  • Temporomandibular: Inner horizontal part limits posterior movement, outer oblique limits rotation
  • Sphenomandibular: Limits excessive mouth opening

2

TMJ blood supply

 

Posterior - Masseteric

Anterior - Maxillary, STA

3

TMJ innervation

Auriculotemporal

4

Scintigraphy

Isotope for bone remodeling (taken up by what cell?)

Isotope for inflammation, good for osteomyelitis

Technetium 99, osteoclasts

Gallium 67, tumor cells, inflammatory cells

5

Non-surgical Rx management TMD

5 medicine classes, common med and dose

  • (NSAIDs): 600 mg of ibuprophen four times daily, 500 mg of naproxen twice daily
  • Steroids: Medrol Dosepak (P"zer)
  • Muscle relaxants: 5 to 10 mg cyclobenzaprine TID
  • Antidepressants: Reduces muscle tension; 10 mg amitriptyline QID
  • Anxiolytics: Reduces muscle tension; 0.25 mg alprazolam BID or 5 mg diazapam QID

6

3 splints for non-surgical TMD

  • Stabilization Splint: flat, full coverage, prevents grinding only
  • Modified Hawley: anterior teeth coverage, prevents grinding and clenching
  • Repositioning splint: full coverage, incline to guide mandible anteriorly. Must monitor for shifting dentition

7

OA vs RA in TMJ

  • Age
  • Prevalence
  • Duration of morning stiffness
  • Swelling
  • Speed of onset
  • Unilateral vs bilateral

OA

  • older age
  • 8-16% OA have TMJ involvement
  • AM stiff <1 hr
  • No swelling
  • Gradual onset
  • Often unilateral

RA

  • Any age
  • 50% RA have TMJ involvement
  • AM stiff >1 hr
  • Swelling, pain, stiff
  • Rapid onset (weeks)
  • Often bilateral

8

JRA

  • Age
  • Diagnosis
  • Labs (3 key labs)
  • What % JRA have TMJ involvement
  • Tx

  • 1-12 yrs old
  • Clinical, PE, Rad: progressive class II with open bite, bird beak deformity, condyle resportion, pain, limited function, preauricular swelling
  • RA factor 20% of patient's, ANA 60-80% of patients, Elevated ESR
  • 50% JRA have TMJ involvement
  • NSAIDS, antirheum agents, surgery once disease controlled

9

RA synovial fluid findings

Cloud

Reduced Viscosity

WBC >20,000

10

Psoriatic Arthritis

  • clinical triad
  • Treatment
  • What % of people with cutaneous psoriasis have psoriatic arthritis

  • psoriasis, erosive arthritis, negative RF
  • Medical only: NSAIDS, steroids, disease modifiers
  • 33%

11

Reactive Arthritis (Reiter Disease)

  • Triggered by:
  • Triad

  • Triggered by infection: intestinal, STD
  • Triad: Cannont:
    • Climb (arthritis)
    • See (Uveitis)
    • Pee (urethritis)

12

Infectious arthritis

  • Local etiologies
  • Systemic etiologies
  • Lab findings
  • Key physical findings
  • Treatment

  • Ear/mandible infection, trauma
  • Hematogenous spread of: Gohnorrhea, syphyllis, TB, actinomyces
  • Leukocytosis, TMJ aspirate culture
  • Preauricular skin warm, erythema

13

Still Disease 

  • Similar to what disease
  • Gender/Age
  • Diagnosis
  • Lab findings

  • Similar to JRA except boys
  • Boys, <5yo
  • Fever, joint swelling and pain, hepatosplenomegaly, lymphadenopathy

14

Gout vs Pseudogout

  • Crystal type and shape
  • Birefringence
  • Imaging
  • Lab values

  • Gout - needle shapes
  • pseudogout - rhomboid shape

 

  • Gout - Monosodium urate monohydrate
  • pseudogout - Calcium pyrophosphate dehydrate

 

  • non-specific chronic destruction, intracapsular calcification
  • Gout - elevated serum uric acid

15

Gout vs Pseudogout

  • etiology
  • risk factors
  • age/gender
  • affected joints
  • prophylaxis

  • Gout - excess uric acid production/undersecretion
  • Pseudogout - excess inorganic pyrophosphate

 

  • Gout - purine rich diet, EtOH, diuretics
  • pseudogout - RA, hypothryroid, hyperparathyroid, 

 

  • Gout - Males 40+
  • pseudogout - Females 60+

 

  • Gout - small joints of hand, feet, elbow, knee
  • pseudogout - TMJ, triangular ligament of hand, knee meniscus

 

  • Gout - Colchicine, low-purine diet
  • pseudogout - Colchicine

16

High Purine foods

  • Foods high in purine include organ meats, bacon, anchovies, venison, veal, goose and yeast. Certain seafood
  • Mushrooms, black gram, beans, peas, lentils, broccoli, cauliflower, carrots, aubergine and spinach.
  • Yeast 

17

Disc Displacement %

Anterior

Posterior

Medial rotation

Anterolateral

  • Anterior 45%
  • Posterior <15%
  • Medial Rotation 30%
  • Anterolateral 11%

18

Synovitis mediators

  • What is released
  • Affect of each

  • Prostaglandin E
  • Leukotriene B4

 

  • Both cause vasodilation with edema/hyperemia

19

Wilkes Classification

Common stages

  • Painful click
  • Disc perforation
  • Moderate bony changes
  • Complete disc displacement without reduction
  • Occasional painful click

  • Painful click - Stage II
  • Disc perforation - Stage V
  • Moderate bony changes - Stage IV
  • Complete disc displacement without reduction - Stage III
  • Occasional painful click - Stage I

20

Arthrocentesis

  • Rate of success

  • 80-85% successful

21

Stage of Acute Synovitis

  • Type 1
  • Type 2
  • Type 3
  • Type 4

• 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

22

Hemimandibular Hyperplasia vs Elongation

  • Why is there a crossbite and chin deviation in one type?
  • Why is there open bite in other type

  • Cross bite and chin deviation in Elongation because mandibular length is increased
  • Ipsilateral posterior open bite in hyperplasia

23

TMJ Ankylosis Classification

  • Topazian
  • Sawhney

Topazian: Inferior extension of ankylotic bone

  • stage 1: bone limited to condyle
  • stage 2: bone extends to notch
  • stage 3: bone extends to coronoid

 

Sawhney: Sequence of fibrous adhesions to relacement of joint with bone

  • type 1: fibrous adhesions
  • type 2: bony fusion (usually only at lateral aspect)
  • type 3: bony bridge between ramus and arch/temporal bone
  • type 4: joint replaced with bony mass

 

24

Anklysosis: 4 etiologies

  1. Trauma example?
  2. Infection exampl?
  3. Inflammation examples?
  4. Surgery example?

Anklysosis: 4 etiologies

  1. Trauma (esp pediatric condyle)
  2. Infection (otitis media, suppurative TMJ arthritis)
  3. Inflammation (RA, ankylosing spondylitis)
  4. Surgery (post op complication TMJ surgery)

25

TMJ tumor types

  • 3 categories of TMJ tumors
  • Rank in order of occurence

Pseudotumor 70%

Malignant neoplasm 20%

Benign neoplasms 10%

26

TMJ neoplasms - radiographic findings

  • Radioopacity: likely lesions
  • Radiolucency: likely lesions
  • Mixed: likely lesions

  • Radioopacity: likely pseudotumor
  • Radiolucency: likely benign/malignant
  • Mixed: Osteoid Osteoma, osteosarcoma

27

List 3 TMJ pseudotumors and one liner

  1. Osteochondroma: Condylar periosteum metaplasia, ossification continuous with condyle cortical bone tx with resection.
  2. Pigmented Villonodular Synovitis: proliferation of synovium, pigmented from hemosiderin, tx with synovectomy and capsulectomy.
  3. Synovial Chondromatosis: Synovial metaplasia to cartilage, chunks dettach forming joint mice, tx with synovectomy

28

List 2 Benign TMJ Tumors and one liner

 

  1. Osteoma: Hyperplasia normal bone usually <2cm, condyle often replaced, NSAIDs help, tx with resection
  2. Osteoid osteoma: Less bone and more vascularized fibrous stroma >2cm, mixed radiograph lesion, giant cells unique feature, NSAIDs don't help, tx with curretage.

29

Malignant TMJ Tumors - most common

  • most common TMJ malignancy is metastasis

30

Primary Malignant TMJ Tumors

All are Sarcomas. 3 types and one liner

  1. Osteosarcoma: most common, single poorly defined lytic lesion on radiograph, mets to lungs, tx with pre/post op chemo
  2. Chondrosarcoma: erosion of condyle with joint space calcifications, high grade 70% metastasis rate, Tx resection and adjuvant XRT
  3. Synovial Sarcoma: Originates from synovium, tx with WLE and adjuvant chemo/XRT