TMJD Flashcards
1
Q
Size of the problem (3)
A
Percentage of population with signs (at some point in their life) 50-75%
Percentage of population with symptoms (at some point in their life) 20-25%
Percentage of population who seek treatment 3-4%
2
Q
Anatomy of the TMJ (5)
A
• Mandible bone -condyle -coronoid process • Temporal bone -mastoid process -digastric muscle -external auditory meatus • Temporomandibular joint • Zygomatic arch • Movement and muscles • Cervical spine and TMD
3
Q
What envelopes the joint? (1)
A
The fibrous articular capsule
4
Q
Describe the articular disc (2)
A
Biconcave disc
Disc divides joint into upper and lower compartments
5
Q
Hinge joint - lower compartment (1)
A
Condyle rotates about the disc
6
Q
Hinge joint with a moveable socket - upper compartment (1)
A
Condyle and disc translate along eminence
7
Q
How much should the mouth open? (2)
A
35-50mm
3 fingers
8
Q
Describe mouth opening in terms of TMJ (2)
A
First half of opening mainly hinging (rotation of condyle in the fossa)
Second half of opening mainly forward translation of condyle along eminence
9
Q
Muscles in TMJ movements (4)
A
Combination of muscle action produces the rotation and translation movements
Geniohyoid and digastric pulls the chin down and backwards
Lateral pterygoid - forward translation of condyles and discs
Temporalis (posterior fibres) - backward translation of condyles
Temporalis, masseter and medial pterygoid elevate the mandible
10
Q
Protrusion - distance and muscles (3)
A
10mm
Symmetrical forward translation of both condyles
Both lateral pterygoids pull condyles (and discs)
11
Q
Retrusion - movement and muscles (2)
A
The return to rest position from protrusion position
Both temporalis muscles (posterior fibres) pull condyles
12
Q
Lateral excursion - distance and movement
A
10mm
The condyle of opposite side is pulled forward
Condyle on the same side performs minimal rotation around vertical axis
Contraction of the lateral pterygoid muscles on opposite side
Combined with temporalis muscle on the same side contracting to hold the rest position of the condyle
13
Q
Diagnostic classification - non TMDs (other facial pains) (3)
A
Dental
Salivary gland
Pharynx etc.
14
Q
Diagnostic classification - uncommon TMDs (specific) (3)
A
Inflammatory arthritis
Neoplasms
Growth disturbance etc.
15
Q
Diagnostic classification - common TMDs (5)
A
Acute or chronic (>3 months) Muscular Articular -disc displacement -osteoarthritis -subluxation -adhesions Muscular and articular
16
Q
Common TMD - stats (2)
A
Account for over 95% of all referrals
Diagnosis is made on the basis of history and
examination
17
Q
Define common TMD (4)
A
A collective term embracing a number of clinical problems that involve: o the masticatory muscles o the temporomandibular joint & associated structures o or both
18
Q
Classification of common musculoskeletal TMD (3)
A
• Masticatory muscle disorders
• Temporomandibular joint disorders
• Headache attributed to TMD
Mixed presentation is common
19
Q
Masticatory muscle disorders (2)
A
Local myalgia
Myofascial pain
• Commonly associated with painful guarded muscles of mastication
• Parafunctional activity believed to be common driver
20
Q
Masticatory muscle disroders - sign and symptoms (3)
A
- Pulling / tight aching sensation
- Pain with jaw activity
- Tenderness on palpation
21
Q
Myofascial pain (3)
A
• Presence of trigger points (TPs)
• Hyper-irritable taut band of muscle tissue which
on palpation reproduces local and referred pain
• Inactivation relieves pain
22
Q
Myofascial pain - cause of TPs not well understood (3)
A
? Neuro-chemical changes:
o Hyperalgesia due to sensitisation of NS
o Elevated levels of pain mediators have
been found near trigger points in muscle
23
Q
TMJ arthralgia (4)
A
Disc displacement o With reduction o Without reduction Osteoarthritis / osis Hypermobility & subluxation Adhesions
24
Q
Disc displacement with reduction (DD + R) (2)
A
- Progression of TMJ hypermobility
- TMJ becomes more lax and the ideal disc position is no longer maintained in relation to the condyle throughout the range of motion
25
Disc displacement with reduction (DD + R) - signs and symptoms (2)
Click with opening/ closing
| Deviation to ipsilateral sides
26
Disc displacement without reduction (DD - R) (2)
* Progression of disc displacement with reduction
| * Here the disc no longer relocates
27
Disc displacement without reduction (DD - R) - signs and symptoms (4)
```
Acute / subacute – ‘closed lock’
• Limited opening (< 25 mm)
• Ipsilateral deviation with opening
• Limited contralateral excursion
Chronic
• Joint can become stretched to allow nearly full ROM
```
28
Osteoarthritis / osis (1)
Common and ‘may’ be an added source of pain and limited ROM
29
Osteoarthritis / osis - signs and symptoms (3)
```
TMJ crepitus
Tenderness on palpation of TMJ
Radiographic (OPG)
-joint space narrowing
-osteophytes
-subchondral sclerosis (increased opacity)
-subchondral cysts
```
30
Hypermobility and subluxation (1)
TMJ hyprtmobility can result in recurrent condyle subluxation
31
Hypermobility and subluxation - signs and symptoms (3)
* Excessive AROM with opening (> 40 mm)
* Click at EOR opening
* Open lock
32
Adhesions - possible causes (5)
Adhesions limit extensibility of TMJ capsule – possible causes:
o Chronic inflammatory condition
o History of trauma or surgery
o Immobilisation
o Chronic articular disc displacement without reduction
33
Adhesions - signs and symptoms (3)
* Limited opening
* Ipsilateral deviation with opening
* Limited contralateral excursion
34
Headache secondary to TMD - signs and symptoms (4)
* Ache in temple area/s
* Aggravated with jaw movement, function, or parafunction
* Pain on movement testing
* Pain on palpation of temporalis muscle/s
35
History of disorder - clicking (5)
```
oOn opening or closing
oAggravating / relieving
oTiming
oTemporary or persistent
oAssociated with pain
Other joint noises
```
36
History of disorder - limitation of opening / trismus (3)
o Duration
oAggravating / relieving
oAssociated with pain
37
History of disorder - locking (4)
* On opening or closing
* Timing
* Temporary or persistent
* Associated with pain
38
History of TMJD (8)
```
Clicking
Other joint noises
Limitation of opening/ trismus
Locking
Altered occlusion
Sensory disturbance
History of trauma
Parafunctional activity
```
39
History of disorder - parafunctional activity (3)
o Clenching / grinding
o Nail biting
oLip biting
40
Chronic pain in TMD (4)
TMD that lasts for a considerable period of time may lead
to substantial psychological distress and behavioural
reactions. For example:
o Not working
o Restricted social pattern
o Depression
This is then termed ‘dysfunctional pain’
41
Three risk factors for TMD as chronic pain (3)
1. Predisposing – trauma
2. Initiating – microtrauma and strain
3. Perpetuating – psychological and parafunctional
42
Possible PMH for chronic TMJD (5)
* Systemic arthritis
* Previous malignancy
* Mental health (depression / anxiety)
* Fibromyalgia
* Hypermobility syndrome
43
What is fibromyalgia? (3)
• Widespread pain and sensitivity to palpation at
multiple anatomically defined tissue sites
• Often accompanied by depression and insomnia
• Thought to be due to CNS neurosensory amplification
44
History suggesting fibromyalgia (5)
History of cancer (may suggest metastasis).
Pain that is abrupt in onset, severe, or precipitated by exertion, coughing, or
sneezing, or that interrupts sleep (may suggest intracranial pathology or cardiac ischaemia).
Weight loss (may suggest cancer).
Fever (may suggest septic arthritis, osteomyelitis, intracranial abscess, tooth
abscess, or mastoiditis).
Neurological symptoms or signs (may suggest a tumour or other intracranial
pathology).
45
Facial signs/ symptoms of fibromyalgia (5)
Swelling of the temporomandibular joint,
mandible, or parotid gland (may suggest tumour, infection, or inflammatory
arthropathy).
Facial asymmetry (may indicate a tumour).
Unilateral headache or scalp tenderness, jaw claudication, or visual symptoms (suggests giant cell arteritis).
Nasal symptoms — persistent loss of smell (anosmia), purulent discharge, nasal
blockage, or epistaxis (may suggest a nasopharyngeal tumour).
Neck mass or persistent cervical lymphadenopathy (may suggest infection or
tumour).
Change in occlusion (how the teeth meet together when the jaws are closed). This
may suggest a tumour or bone growth (for example in acromegaly) around the
temporo-mandibular joint, or inflammatory arthritis; but can also be seen in other
temporomandibular disorders.
Decreased hearing on the ipsilateral side (may suggest a nasopharyngeal tumour).
Increasing pain or limitation in function despite initial management (may suggest a
tumour).
46
Extra-oral examination for TMJD (4)
```
Observation
Neurological
Vascular/ arteries
-temporal arteritis
Lymph nodes
-infection, inflammation, neoplasm
```
47
Intra-oral examination (6)
```
Signs of clenching/ grinding
-tongue scalloping/ buccal mucosal ridging
-attrition/ wear facets
-hypertrophic masseter muscles
Occlusal assessment
-interfering contacts
-recent changes in occlusal scheme
-skeletal pattern - class II 'posturing'
```
48
Musculoskeletal examination
```
Observation of movement
-opening: pattern, range, overpressure, sounds
-lateral excurstion
-protrusion
Palpation
-temporomandibular joint
-muscles (extraoral, intraoral)
```
49
Bruxoprovocation test (1)
1 minute clench test
50
Investigation
Radiographic
51
Treatment - main forms (3)
Education
Exercises - physiotherapy
Splint therapy
52
Treatment - other forms (6)
```
Medication
Occlusal adjustments
Botulinum toxin
Arthrocentesis
Surgery
Review
```
53
Treatment: education (3)
Information
Principles of treatment
Reassurance
54
Aims of intervention (5)
```
Reduce pain
Recover function
Improve psychological status
Self-manage
Be safe!
```
55
Persistent TMD will usually be associated with (2)
a complex combination of driving factors
that can coexist to maintain an ongoing
cycle of pain and disability
56
Driving factors of TMD (8)
```
Lifestyle
BIOLOGICAL
Patho-anatomical
Neuro-psychological
Physical
Comorbidities/ genetic
PSYCHOSOCIAL
Cognitive
Psychological
Social
```
57
Explanation of psychological intervention (7)
Crucial for addressing psychological driving factors
-helps reassure and reduce threat of symptoms
Improves compliance with tx
-helps motivate by providing a rationale
Based on assessment findings, reinforce benign TMD 'diagnosis'
Explain how ongoing cycles can be maintained
Ask the pt about their main problems and goals
Ask what they could do to help break their cycle of pain
58
How can I reduce stress/ strain on my jaw joint and jaw muscles? (6)
Avoid oral habit e.g. clenching, nail biting, lip sucking etc.
Regularly check your 'relaxed' jaw rest position
-remember to keep tongue up, teeth apart
Avoid a 'forward' head posture (increases activity in neck and jaw muscles)
Eat soft diet, cut food into small pieces, chew slowly
Avoid caffeine
Avoid excessive or prolonged mouth opening
-there are lots more
59
Trigger-point inactivation/ acupuncture (3)
• To facilitate muscle relaxation and reduce pain
• ‘It appears that the mechanical disruption of the trigger point by the needle provides the therapeutic
effect’
• Follow this with muscle stretching
60
Passive joint stretch/ self-mobilisation (3)
1. On side to be stretched slide sticks
between the back teeth to take up slack, maintain relaxed open position
2. Holding sticks, gently and slowly move in upward direction so you feel a gentle stretch on your jaw
joint on that side - not a forced stretch
• 10 repetitions every 2 hours
61
Active-assisted stretch (4)
Slowly open as wide as comfortable
Assist opening with index finger and thumb 'scissor action'
3x10 second holds, every 2 hours
SLOW movements without pain or undue force
62
TMDs and occlusal splint therapy (2)
Interocclusal appliance therapy (occlusal splint)
| -removable device usually made of acrylic resin, which fits between maxillary and mandibular teeth
63
How do splints work? (6)
* Occlusal disengagement
* Maxillo-mandibular realignment
* Restored vertical dimension
* TMJ repositioning
* Cognitive awareness
* Placebo effect
64
Types of splint (4)
```
Directive
-anterior repositioning splint (ARPS)
Permissive
-soft bite guard
-anterior bite plane (Lucia jig)
-stabilisation splint (Michigan, Tanner)
```
65
Anterior repositioning splint (2)
• Used to direct the mandible more anterior to ICP
• Provides a better condyle-disc relationship to
allow time for the tissues to adapt or repair
66
Indications of anterior repositioning splint (2)
• Disc derangement disorders (especially anterior disc displacement with reduction)
• Can be useful for intermittent / chronic
locking of the joint (often caused by disc displacement)
67
Advantages of soft splints (3)
Sometimes tolerated better by patients
Easily constructed
Cheap
68
Disadvantages of soft splints (3)
Difficult to adjust
Can encourage patient to brux
In some cases muscle pain either does not change or occasionally increases
69
Lucia jig (2)
• Used to disclude posterior teeth and allow relaxation
of the muscles of mastication
• Patients “forget” their ICP position (neuromuscular
deprogramming)
70
Uses of the Lucia jig (3)
• To help locate centric relation
• As a diagnostic tool for patients with TMD symptoms
• As a “quick fix” for patients with acute symptoms, prior to constructing a more
definitive appliance
71
Ask stabilisation types (5)
* Michigan splint (upper)
* Tanner appliance (lower)
* Interocclusal appliance
* Occlusal splint
* Ramfjord appliance
72
Features of a stabilisation splint (6)
```
• Maxillary splint
• Heat-cured acrylic
• Full coverage to prevent over-eruption
• Uniform contact in centric relation
• Canine guidance to separate posterior teeth in
eccentric excursions
• Anterior guidance to separate posterior teeth in
protrusion
```
73
Clinical stages of splint construction (3)
```
Visit 1
• Upper and lower alginate impressions
• Jaw registration in centric relation
• Facebow
Visit 2
• Fit splint
Subsequent visits
• Review and adjust as necessary
```
74
Clinical procedures in splint construction (3)
• Maxillary and mandibular alginate impressions
• Facebow transfer
• Centric relation jaw registration
• Records to laboratory
• Fitting the splint - seat and adjust fitting surface as necessary
-bilaminate splints make fitting easier
75
Pattern and duration of splint wear for TMD patients (3)
• Every night
• During periods of increased muscular activity/ stress
• For patients with severe symptoms, as often
as possible during the day also
76
Design features of a Tanner appliance (6)
```
• Mandibular appliance
• Heat-cured acrylic resin
• Full occlusal coverage
• Simultaneous, even contacts with all opposing teeth in RCP
• Appropriate anterior guidance
• Absence of posterior
interferences
```
77
Following splint therapy (2)
• If the splint therapy is successful in
reducing/ eliminating symptoms consider
long-term splint wear
• Do not assume that further intervention
(e.g. occlusal adjustment) will provide the same benefit
78
Anxiolytics for TMD (3)
Tricyclic antidepressants
-muscle relaxation
-analgesia
Benzodiazepines - caution
79
Arthrocenesis (2)
Injection of steroids
| Upper joint space
80
Arthroscopy (4)
Adhesiolysis
Lavage
Biopsy
Miniscal plication
81
Advantages (2) and disadvantages (2) of arthrocenesis and arthroscopy
```
Advantages:
-minimally invasive
-diagnostic information
Disadvantage
-limited scope for reconstructive surgery
-requires a high level of operator skill
```
82
Surgery for TMD (5)
* Condylar hyperplasia
* Trauma
* Ankylosis
* Tumours
* Internal derangement and severe chronic pain that is refractory to non-surgical treatment
83
Risks of surgery (2)
```
Auriculotemporal nerve
Facial nerve (zygomatic; temporal branches)
```
84
Diskoplasty (1)
Disc repositioning (plication)
85
Diskectomy (1)
Disc removal ± alloplastic material / temporalis
| muscle flap
86
Trauma and dislocation (3)
* Traumatic arthritic / effusion
* Dislocation
* Fracture
87
Osteoarthritis definition (2)
also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving degradation of joints
– including articular cartilage and subchondral bone
88
Clinical features of osteoarthritis (6)
* Pain centred on the joint
* Tender joint
* Crepitus
* Limitation of mouth opening
* Limitation of translatory movement
* Radiological signs (erosions, spurs)
89
Treatment for osteoarthritis??***
```
Symptomatic
o Splints
o BRA
o NSAID
Arthrocentesis
```
90
Infective arthritis - description and clinical features (8)
```
Rare
May spread to middle cranial fossa therefore must be treated urgently
Clinical features
• Pyrexia
• Very restricted opening
• Suppuration
• Erythema
• Swelling
• Long term ankylosis
```
91
Treatment for infective arthritis (2)
* Antibiotics (IV)
| * Drainage
92
Extracapsular features of ankylosis and limited opening (5)
* Trauma → fibrosis (burns, trauma, lacerations)
* Infection
* Tumours (e.g. fibroscarcomas)
* Periarticular fibrosis (radiation, prolonged immobilization)
* Inflammation (dental, other)
93
Intracapsular features of ankylosis and limited opening (5)
* Trauma → fracture (forceps delivery at birth)
* Infection
* Systemic arthritis
* Tumours
* Synovial chondromatosis (multiple cartilaginous nodules within the TMJ) – very rare
94
Pseudo-ankylosis (1)
• Mechanical interference with mouth opening (e.g. zygomatic fracture)
95
Trismus checklist (6)
For completion in pts with reduced mouth opening
-opening less than 15mm
-progressively worsening trsimus
-absence of history of clicking
-pain of non-myofascial origin (neuralgia etc.)
-swollen lymph glands
-suspicious intra-oral soft tissue lesion
If any are yes consider radiograph and arrange review with senior clinician
96
Recurrent TMJ dislocations (4)
* Physiotherapy
* Botulinum toxin (lateral pterygoid)
* Fibrosis of the tissues
* Surgical
97
Inflammatory arthritis associations (5)
* Rheumatoid (also juvenile)
* Psoriatic
* SLE
* Ankylosing spondylitis
* Gout
98
TMJ replacements (2)
• Made of two parts – ball and socket system
• Reserved for cases where
all other treatment
modalities have failed
