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oral surgery 4th year > TMJ summary > Flashcards

TMJ summary Flashcards

1
Q

which part of the disc is innervated?

A

bilaminar zone

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2
Q

fct of ligaments

A

surround joint capsule - stability, protect against extreme movements

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3
Q

ligaments

A

lateral ligament - limits AP joint movement

sphenomandibular and stylomandibular - limit lateral movements

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4
Q

describe the disc

A

fibrocartilage
avascular
biconcave

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5
Q

articulating surface of condyle

A

fibrocartilage

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6
Q

articular eminence

A

temporal bone

dictates path of condyle during mandibular movements

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7
Q

glenoid cavity/fossa

A

hollow on inferior surface of squamous temporal zone

fibrocartilage

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8
Q

capsule

A

thin fibrous CT attached to rim of fossa and neck of condyle
disc attaches to it medially and laterally
lat aspects thickened by TM ligament

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9
Q

blood supply

A

deep auricular artery

- branch of internal maxillary artery

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10
Q

nerve supply

A

auriculotemporal, masseteric, posterior temporal nerves

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11
Q

superior joint compartment

A

gliding

protrusion, retrusion, side to side

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12
Q

inferior joint compartment

A

rotation

elevation and depression

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13
Q

what does the disc blend with?

A

anteriorly blends with LP margins
posteriorly attached to bilaminar zone - loose CT and nerves
lined with synovial membrane

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14
Q

suprahyoids

A

digastric
mylohyoid
geniohyoid
stylohyoid

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15
Q

infrahyoids

A

thyrohyoid
sternohyoid
omohyoid
sternothyroid

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16
Q

synovial membrane

A

lines non-articular surfaces

produces the synovial fluid that lubricates the joints and nourishes the cartilage

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17
Q

when is the joint loaded?

A

eating or clenching

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18
Q

superficial MofM

A

temporalis

masseter

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19
Q

deep MofM

A

LP

MP

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20
Q

what supplies the MofM

A

motor branches of V3

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21
Q

origin and insertion of temporalis

A

temporal fossa

tendon onto coronoid process

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22
Q

fct of temporalis

A

elevate (anterior vertical fibres)

retract (posterior diagonal/horizontal fibres)

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23
Q

origins of masseter

A

superficial - maxillary process of zygomatic bone

deep - zygomatic arch of temporal bone

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24
Q

insertion of masseter

A

lateral surface ramus and angle mandible

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25
Q

fct of masseter

A

elevate mandible

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26
Q

origins of MP

A

superficial - maxillary tuberosity and pyramidal process of palatine bone
deep - medial aspect LP plate (sphenoid)

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27
Q

insertion MP

A

medial surface ramus/angle

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28
Q

fct of MP

A

elevates (bilateral)

swing jaw to contralateral side (unilateral)

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29
Q

origins of LP

A

superior head - greater wing of sphenoid, roof of infratemporal fossa
inferior head - lat surface LP plate

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30
Q

insertion of LP

A

tendon - joint capsule and neck of condyle. pterygoid fovea

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31
Q

fct of LP

A

protrudes and depresses - bilateral

lateral excursions - unilateral

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32
Q

depressing the mandible

A

infra and suprahyoids act together: hyoid bone stabilised
suprahyoids contract further - pulls down on mandible
LPs contract - translates condyles down articular eminence
also assisted by gravity

= forward and downward movement of mandible

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33
Q

initial mouth opening

A

hinges from centric relation up to 25mm

  • aided by supra/infrahyoid contraction
  • LPs relaxed
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34
Q

further mouth opening

A

to max opening - condyle translates anteriorly (forwards and downwards) along articular eminence
- bilateral contraction of LPs and contraction of supra and infrahyoids

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35
Q

protrusion

A

condyle translates forwards and downwards along the articular eminence
bilateral contraction of LPs

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36
Q

mouth closing

A

condyle held within glenoid fossa

aided by contraction of temporalis, masseter and MP

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37
Q

when is the jaw most stable?

A

when mouth closed and teeth in occlusion

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38
Q

lateral excursion

A

mandible moves to left
left condyle pulled backwards slightly by the temporalis and rotates but sits within the glenoid fossa
R condyle moves forwards, downwards and inwards along articular eminence - R LP contracts
posterior fibres of L temporalis contract

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39
Q

TMD definition

A

collective term “a group of conditions that cause pain and dysfct in the jaw joint and muscles that control jaw movement’

  • masticatory muscles
  • TMJ and associated structures
  • both
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40
Q

basic classification

A

disorder of the MofM
disorder of the TMJ
headache attributable to TMD

= often they co-exist

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41
Q

basic classification - disorder of the MofM

A

usually caused by parafct habits

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42
Q

basic classification - disorder of TMJ

A 
disc displacement +/- reduction
osteoarthritis
osteoarthrosis
hypermobility
subluxation
adhesions
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43
Q

Groups of TMD

A

Group 1 - muscle disorders
Group 2 - disc displacement
Group 3

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44
Q

Group 1 - muscle disorders

A

1a - myofascial pain

1b - myofascial pain with limitations in aperture

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45
Q

Group 2 - disc displacement

A

2a - disc displacement with reduction
2b - disc displacement without reduction and no limitations in aperture
2c - disc displacement without reduction and with limitations in aperture

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46
Q

soft end feel

A

pt guarding against opening due to pain

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47
Q

hard end feel

A

can’t open any further

48
Q

Group 3

A

3a - arthralgia (pain)
3b - osteoarthritis of TMJ
3c - osteoarthrosis of TMJ

49
Q

masticatory muscle disorders

A 
local myalgia (pain felt locally within muscle)
myofascial pain (pain felt within and referred outside of the muscle)
50
Q

common cause of masticatory muscle disorders

A

parafct activity
- clenching, grinding, biting nails, chewing gum
can be thought of as overworking the muscles almost causing a sprain-like injury

51
Q

S+S of MM disorders

A

tender muscles on palpation
pain with jaw activity i.e. speaking, chewing
pulling, tight or achey sensation

52
Q

disc displacement with reduction tx

A 
no pain = no tx
tx
 - advice
 - limit opening
 - BRA
 - occ surgery
53
Q

disc displacement with reduction pathogenesis

A

ideal disc position no longer maintained in relation to the condyle throughout range of motion
disc initially displaced anteriorly by the condyle during opening until disc reduction (relocation) - click

54
Q

S+S of disc displacement with reduction

A

click on opening and closing
deviation of jaw to affected side (same side) on opening
if left untxed may eventually progress to OA

55
Q

disc displacement without reduction pathogenesis

A

disc anteriorly displaced and no longer reduces (relocates)

56
Q

S+S of disc displacement without reduction

A

“closed lock” - limited opening 25mm - disc displacement without reduction with reduced mouth opening
deviation of jaw to same side on opening
limited contralateral excursion i.e. if left joint is affected there is limited jaw movement to right
if chronic the joint can become stretched and allow a nearly full range of movement
- history of limited opening but not anymore and MRI showing remodelling
- disc displacement without reduction without limited mouth opening
get pain as bilaminar zone innervated

57
Q

osteoarthritis

A

deterioration of joint, often relating to condyle

58
Q

S+S of osteoarthritis

A

pain and crepitus (grating/grinding)
radiographic features
- joint space narrowing
- osteophytes

59
Q

osteoarthrosis

A

same signs and changes as osteoarthritis but no pain, just crepitus
moth eaten condyles

60
Q

hypermobility

A

excessive range of movement which may lead to subluxation

61
Q

subluxation

A

dislocation of joint - condylar process beyond articular tubercle

62
Q

subluxation causes

A

excessive mouth opening
yawning
trauma
prolonged dental tx/intubation

63
Q

presentation of subluxation

A

malocclusion
open bite
empty articular sockets - palpate as pre-tracheal hollowing
if unilateral - chin shifted to contralateral side
click palpated at max opening
open lock may result - jaw is ‘stuck open’
- MofM spasm and hold mandible in this position

64
Q

subluxation preventive aftercare

A

support chin
limit opening
can use circular fixation bandage for 24hrs

65
Q

subluxation - when should you not relocate?

A

if you suspect any facial fractures

66
Q

subluxation relocation

A

ASAP as may avoid need for additional measures i.e. muscle relaxants/sedation/GA
chair with head support
one side at a time
put downward pressure on L molars with thumb and grip mandible with rest of hand (fingers buccal sulcus)
increasing force until you feel condyle move
then hold in position with non-dominant hand by one finger in front of condyle
relocate other side
verify normal occlusion

67
Q

complications of subluxation

A

unable to reduce
subcondylar fracture
early repeat redislocation

68
Q

adhesions

A

limit extensibility of joint capsule

  • chronic inflammation
  • history of trauma/surgery
  • immobilisation
  • chronic disc displacement without reduction
69
Q

S+S of adhesions

A

limited opening
deviation to same side on opening
limited contralateral excursion

70
Q

multifactorial aetiology - biopsychosocial model

A

biological: inflammation
- local factors: secondary to parafct, trauma, infection, tooth loss, prolonged dental procedures
- systemic factors: arthritis, fibromyalgia, hypermobility (EDS)
psychological: anxiety, depression, thoughts, beliefs
social: work, finances, family, relationship

71
Q

HPC key points

A 
pain
 - associated pain elsewhere e.g. neck, shoulders
clicking
other noises e.g. grating
limitation of opening
locking
altered occlusion
sensory disturbance
history of trauma
parafct activity
what have they prev tried and did it help?
opening/closing
aggravating/relieving factors
temp/persistent
timing and duration
 - morn bruxism
 - day habits
72
Q

MH key points

A 
arthritis
prev malignancy
immunosuppression
mental health
fibromyalgia
hypermobility syndromes
73
Q

SH key points

A 
occupation
stress
home circumstances
sleeping pattern
recent family difficulty or bereavement
relationships
74
Q

DH key points

A 
recent tx (in particular lengthy or difficult appts)
surgical procedures (recent 3rd molar removal)
denture wearers
75
Q

why should you palpate the neck?

A

some pts can present with tenderness of SCM

76
Q

how to palpate masseter

A

bimanual palpation

  • one finger inside cheek and one EO over masseter
  • clench then slightly part teeth
  • palpate inferior, mid and superior aspects
  • presence/absence of tenderness/pain
77
Q

TMJ examination

A

palpation
listening on opening and closing
observe lateral excursions and protrusion (10mm)
mouth opening - interincisal distance 35-50mm
mandibular position - posturing habits

78
Q

ideal lateral excursion and protrusion

A

should be smooth unobstructed movement

observe for deviation, restrictions and abnormal sounds

79
Q

what should you do if the pt is guarding due to discomfort/trismus?

A

ask if they can open any further - sometimes use gentle finger pressure

80
Q

ST exam

A

buccal mucosa - linea alba
cheek biting - morsicatio buccarum
bony prominences - tori - associated with overload on teeth
tongue - scalloping

81
Q

examining teeth

A 
wear facets
attrition
occlusion
high spots
teeth present/absent
interfering contacts
occ NCTSL
82
Q

palpating MP

A

one finger inside mouth - slide it posteriorly along your lower teeth past the last standing molar
push finger into the tissues and gently close - you will feel MP contract

83
Q

differential diagnoses

A 
odontogenic pain
sinusitis
temporal (giant cell) arteritis
ear pathology
salivary gland (parotid) pathology
referred neck pain
headache
atypical facial pain
trigeminal neuralgia
angina/MI
burning mouth syndrome
condylar fracture
84
Q

should you routinely image?

A

no - only in special circumstances, not routine investigations

85
Q

plain film

A 
mouth open (allows better visualisation of condyle - can show arthritic changes)/closed OPT
only if joint pathology suspected e.g. arthritic changes
86
Q

CBCT

A

more accurately demonstrates bony anatomy and changes

87
Q

arthrography

A

radiopaque dye injected into joint space using videofluoroscopy
used when meniscal tears suspected

88
Q

MRI

A

ST anatomy inc disc

can detect anterior disc displacement

89
Q

US

A

muscle/ST pathology overlying joint

90
Q

nuclear imaging - technetium 99

A

use for suspected hyperplasia

isotope picked up in areas of increased cell turnover

91
Q

exclude any red flags

A

history of malignancy
lymphadenopathy (persistent/unexplained)
neurological symptoms (headache/CN abnormalities)
facial asymmetry (mass/swelling/profound trismus)
severe unilateral TMJ pain can indicate malignancy
recurrent epistaxis, nasal discharge, anosmia or reduction in hearing (ipsilateral) - nasopharyngeal carcinoma
unexplained weight loss/fever - malignancy, infective, immunosuppression
change in occlusion (neoplasia, RA, trauma etc)
new onset unilateral headache/scalp tenderness, jaw claudication, general malaise, esp if >50yrs - may indicate temporal arteritis (systemic inflammatory vasculitis)

92
Q

broad management categories

A 
reassurance and education
conservative advice
reversible therapies - BRA, physio, acupuncture, hypnosis, clinical psychology, pain clinic, TENS, replacement of missing teeth (esp if lacking posterior support)
meds
surgery
93
Q

meds

A

simple analgesics
BZDs - if seen early during acute exacerbation as muscle relaxant
amitriptyline/nortriptyline (muscle relaxants)
intra-articular steroid injection

94
Q

surgery

A 
botox
high condylar shave
arthrocentesis
arthroscopy
joint replacement
disc repositioning/repair/removal
95
Q

arthrocentesis

A

flushing out joint, often in combination with steroids to break down adhesions

96
Q

arthroscopy

A

visualises joint, can simultaneously remove adhesions/flush joint

97
Q

joint replacement

A

last resort
v rarely used
if no other option and gross pathology present i.e. tumours

98
Q

management of trismus

A

usually resolves spontaneously
identify and tx underlying cause e.g. infection/trauma
improve mouth opening gradually by stretching the muscles and ligaments over weeks/months
physio
- esp H+N radio pts
- therabite, trismus screw, tongue spatulas
a few pts with severe trismus refractory to conventional measures may undergo surgical intervention e.g. coronoidectomy

99
Q

why should a splint always be full coverage?

A

to prevent overeruption

100
Q

when is split therapy offered?

A

as second line tx - if advice is not enough

101
Q

education and reassurance

A

condition usually non-progressive, symptoms may fluctuate but should improve
often self-limiting
can often be managed with simple conservative management
address biopsychosocial aspects
all pts unique so need to find strategies which work for them
- will be trial and error to find right strategies
- can take a couple of weeks to see any benefit

102
Q

conservative advice

A

soft diet
reduce caffeine
avoid parafct activities that may exacerbate symptoms - wide yawning, teeth grinding, clenching, chewing gum or pencils, nail biting
avoid using incisors to slice food
ensure chewing on both sides
keep teeth at least 2mm apart when at rest
limit mouth opening to 2 fingers width
consider simple analgesia for short-term use e.g. paracetamol/NSAID
consider local measures for pain relief - covered ice/warm flannel/heat pad, massaging affected muscles
try to identify sources of stress
- give advice on relaxation techniques, setting realistic targets, pacing activities, getting social support, counselling
support mouth on opening
jaw exercises - physio helps some pts

103
Q

BRAs theory

A

exact mechanism unknown, little scientific evidence to support use
can make better/worse/no effect
theoretically
- stabilise occlusion
- improve fct of MofM
- therefore reduce abnormal activity and protect teeth in cases of grinding

despite lack of evidence, may feel that due to their relative inexpense, non-invasive nature and historical benefit to a significant number of pts, their use is justified

104
Q

soft splint advantages

A

quick, easy, cheap
preferable for clenchers
can be used in teenagers whose occlusion may still be developing
vacuum formed (simple construction)

105
Q

soft splint disadvantages

A

may need regular replacement
may exacerbate condition
difficult to adjust

106
Q

bilaminar splints

A

soft inner, hard outer
slightly more £ but can be simply made by any dental lab
may be better for those who are chewing through soft splints, or where it promotes clenching

107
Q

Wenvac

A

cheap, some chew through/bounce on it as soft and rubbery

108
Q

splint instructions to pt

A

may need to wear splint for several weeks before benefit felt
wear every night
wear at time of parafct - usually sleep, may be driving, using computer, other times of stress
if v severe symptoms wear continuously apart from eating
use may then decrease as symptoms improve, and recommence as symptoms worsen
but many pts continue to wear long term
pt may still clench/grind with splint in situ, but hopefully splint will act as habit breaker
occ splints may worsen a pts problem in which case they should be reassessed
soft splints may occ promote clenching leading to worsening of discomfort - may consider a hard splint

109
Q

which type of splint to use?

A

evidence doesn’t favour any particular splint

  • soft and bilaminar ‘go to’
  • Lucia jigs may be used, particularly in Rx dentistry
  • hard splints may be favoured by those with Rx experience but are rarely constructed in primary care
110
Q

anterior bite plane - Lucia jig

A

discludes posterior teeth to allow relaxation of MofM
used as a v short term measure during acute exacerbations, prior to more definitive splint
may also be used as diagnostic tool for TMD pts
simple to construct chairside - cold cure acrylic or greenstick (can also buy preformed)
airway risk, get dahl effect

111
Q

stabilisation splint

A

Michigan splint U
tanner appliance L
full coverage to prevent over-eruption
creates
- uniform contact in centric relation
- canine guidance to separate posterior teeth in eccentric excursions
- anterior guidance to separate posterior teeth in protrusion
i.e. the splint creates an artificial ‘ideal’ occlusion
complex construction - imps, jaw reg in centric relation, facebow and adjustments at fit appt required
preferable for bruxers

112
Q

pathogenesis

A

inflammation of MofM or TMJ secondary to parafct habits
trauma either directly to joint or indirectly e.g. sustained opening during tx
stress (parafct)
psychogenic
occlusal abnormalities (v rare)
- no evidence, but a Rx that is significantly ‘high’ may cause muscle pain due to posturing

113
Q

common clinical features

A

F>M
most common 18-30yrs
intermittent pain of several months/years duration
muscle/joint/ear pain, particularly on wakening (clenching overnight)
trismus/locking
‘clicking/popping’ joint noises
headaches (temporalis)
crepitus indicates late degenerative changes

114
Q

anterior repositioning splint

A

a maxillary appliance
often used for those with disc derangements
- promotes a more harmonious condyle-disc relationship by capturing an anteriorly displaced disc
directs mandible anterior to ICP

115
Q

causes of TMD

A

myofascial pain
disc displacement (anterior +/- reduction)
degenerative disease
- localised: osteoarthritis (often asymptomatic)
- generalised/systemic: RA
chronic recurrent dislocation
ankylosis
hyperplasia - one condyle larger, asymmetry
neoplasia - osteochondroma, osteoma, sarcoma
infection - rare, usually from ear

116
Q

reversible tx

A

education
meds
physical therapy
splints

117
Q

irreversible tx

A

occlusal adjustment
- DON’T do, no benefit
surgery

oral surgery 4th year (9 decks)

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