1. Tempero-mandibular Joint Surgery and Guidelines PDU 2011 Martin Dodd

2. TMJ Surgery and Guidelines Clinical Anatomy Clinical Anatomy Classification of TMJ disorders Classification of TMJ disorders Non Surgical management Non Surgical management Operative Surgery Operative Surgery Surgical Complications Surgical Complications Guidelines/Literature review Guidelines/Literature review

3. Clinical Anatomy of TMJ Unique “double” joint Unique “double” joint Bone Bone Synovium Synovium Cartilege Cartilege –meniscus Ligaments Ligaments Muscle Muscle Nerve supply Nerve supply

4. Bone Petrous temporal Bone Petrous temporal Bone Mandibular condyle Mandibular condyle

5. Cartilege Tough resilient low friction surface covers Tough resilient low friction surface covers –the condylar head –manibular fossa (glenoid fossa) –articular eminence Meniscus Meniscus –Divides joint space into upper and lower –Allows translational movement

6. Synovium Membrane produces synovial fluid Membrane produces synovial fluid Lubricates Lubricates Nutrition Nutrition Can become inflammed Can become inflammed

7. Ligaments –stabilise the joint Tempero-mandibular ligament Tempero-mandibular ligament Spheno-mandibular ligament Spheno-mandibular ligament Stylo-mandibular ligament Stylo-mandibular ligament

8. Muscles Temporalis Temporalis Masseter Masseter Medial Pterygoid Medial Pterygoid –Elevate mandible Lateral Ptergoid Lateral Ptergoid –Closes mandible –Inserts into meniscus

9. Nerves Hilton’s law Hilton’s law Mandibular divison of the trigeminal nerve Masseteric and auriculotemporal nerves

10. TMJ movement RotationalTranslational

11. Anatomical relations-surgical anatomy

13. Conditions affecting the TMJ TMJDS TMJDS Osteoarthritis/ osteoarthrosis Osteoarthritis/ osteoarthrosis Internal derangement Internal derangement Arthritides Arthritides –Rheumatoid –Psoriatic –Seronegative –Reactive –Septic Trauma Trauma Dislocation/ Subluxation Dislocation/ Subluxation Tumours Tumours –Primary benign/maligmant –Metastatic Condylar Hyperplasia Condylar Hyperplasia Ankylosis Ankylosis

14. Anterior meniscal displacement

15. Anchored disk phenomenon

16. Non Surgical management Pharmacological Pharmacological –Analgesics –NSAID’s –Steroids –Botox –“Muscle relaxants”

17. Non Surgical management Physiotherapy Physiotherapy –Exercises –Acupuncture –Heat treatments –TENS –Biofeedback –Massage Reassurance/behaviour modification Reassurance/behaviour modification

18. Non Surgical management Occlusial splint therapy Occlusial splint therapy –Hard –Soft –Mandibular advamcement

19. Imaging OPT OPT CT scan (bone pathology) CT scan (bone pathology) MRI (meniscal soft tissue pathology, movement disorder) MRI (meniscal soft tissue pathology, movement disorder) Isotope bone scan (Tumours/ hyperplasia Isotope bone scan (Tumours/ hyperplasia

20. Operative procedures for TMJ MUA MUA Arthrocentesis Arthrocentesis Arthroscopy Arthroscopy –Diagnostic –Lysis & lavage –Menisctomy/ –Meniscopexxy Eminectomy Eminectomy Meniscopexy Meniscopexy Menisectomy+/- flap Menisectomy+/- flap TMJ replacement TMJ replacement LESS INVASIVE MORE INVASIVE

21. Manipulation under anaesthetic Indications: –Acute Dislocation –Acute “Closed lock” –Chronic Closed lock Diagnostic –Muscular “trismus”

22. Arthocentesis Indications:- Acute closed lock Acute closed lock Anchored disk phenomenon Anchored disk phenomenon Chronic Closed lock Chronic Closed lock Osteoarthritis Osteoarthritis Septic Arthritis Septic Arthritis Inflammatory arthritides Inflammatory arthritides

23. Arthroscopy Arthroscopy Indications:- Diagnostic Diagnostic Acute closed lock Acute closed lock Anchored disc phenomenon Anchored disc phenomenon Chronic closed lock Chronic closed lock Intra-articular adhesions Intra-articular adhesions

24. EminectomyIndications Recurrent disclocation Recurrent disclocation Acute/chronic closed lock not respnding to arthrocentesis or arthroscopy Acute/chronic closed lock not respnding to arthrocentesis or arthroscopy In conjunction with menisectomy/ meniscopexy In conjunction with menisectomy/ meniscopexy

25. TMJ replacement Ankylosis Ankylosis Tumours Tumours –Benign/(malignant) Inflammatory Arthritis Inflammatory Arthritis Previous Failed Surgery Previous Failed Surgery Post Traumatic Post Traumatic

26. TMJ Replacements Kent prosthesis Kent prosthesis Christensen Christensen Lorenz Lorenz TMJ concepts TMJ concepts

33. Problems with TMJ replacement Infection Infection Cost Cost “Jelly Joint” “Jelly Joint” Revision Surgery Revision Surgery

34. Guidelines

35. Guidelines AADR The AADR recognizes that temporomandibular disorders (TMDs) encompass a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles, and all associated tissues. The signs and symptoms associated with these disorders are diverse, and may include difficulties with chewing, speaking, and other orofacial functions. They also are frequently associated with acute or persistent pain, and the patients often suffer from other painful disorders (comorbidities). The chronic forms of TMD pain may lead to absence from or impairment of work or social interactions, resulting in an overall reduction in the quality of life. Based on the evidence from clinical trials as well as experimental and epidemiologic studies: It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based primarily on information obtained from the patient’s history, clinical examination, and when indicated TMJ radiology or other imaging procedures. The choice of adjunctive diagnostic procedures should be based upon published, peer-reviewed data showing diagnostic efficacy and safety. However, the consensus of recent scientific literature about currently available technological diagnostic devices for TMDs is that, except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups. Currently, standard medical diagnostic or laboratory tests that are used for evaluating similar orthopedic, rheumatological and neurological disorders may also be utilized when indicated with TMD patients. In addition, various standardized and validated psychometric tests may be used to assess the psychosocial dimensions of each patient's TMD problem. It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and evidence- based therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes, they present much less risk of producing harm. Professional treatment should be augmented with a home care program, in which patients are taught about their disorder and how to manage their symptoms. Note: See website for supporting references at www.aadronline.org/i4a/pages/index.cfm?pageid=3465.www.aadronline.org/i4a/pages/index.cfm?pageid=3465

36. Local-Guidelines