1. Chapter 10 Diseases Affecting the Temporomandibular Joint Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 1

2. 2 Outline Anatomy of the Temporomandibular Joint Normal Joint Function Temporomandibular Disorders Tumors of the Temporomandibular Joint

3. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 3 Diseases Affecting the Temporomandibular Joint (TMJ) Disorders of the TMJ include myofascial pain and dysfunction (MPD), internal derangement syndrome, osteoarthritis, and rheumatoid arthritis Benign and malignant tumors can also affect the TMJ

4. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 4 Anatomy of the Temporomandibular Joint (TMJ) The TMJ is an articulation between the condyle of the mandible and the glenoid fossa of the temporal bone

5. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 5 Anatomy of the Temporomandibular Joint Fibrocartilage covers the bony articulating surfaces Ginglymoarthrodial movement An articular disk divides the space Avascular and devoid of nerve fibers Synovial fluid provides nourishment and lubrication

6. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 6 Anatomy of the Temporomandibular Joint A synovial membrane lines the joint and produces synovial fluid that nourishes and lubricates avascular surfaces

7. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 7 Anatomy of the Temporomandibular Joint Palpation of the muscles of mastication may be done to determine whether muscle spasm or dysfunctional muscle activity is occurring Masseter Temporalis Medial pterygoid Lateral pterygoid Anterior digastric Mylohyoid

8. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 8 TMJ: Associated Muscles

9. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 9 Normal Joint Function In the position of maximal occlusal contact, the mandibular condyle rests within the glenoid fossa The articular disk is situated between the condyle, roof of the glenoid fossa, and the articular eminence The first phase of opening is characterized by a rotational (hinge) movement of the condyle followed by an anterior translation (sliding)

10. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 10 Temporomandibular Disorders Pathophysiology of temporomandibular joint disorders Patient evaluation Types of temporomandibular disorders Treatment of temporomandibular joint disorders

11. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 11 Temporomandibular Disorders (TMDs) TMDs are caused by abnormalities in the function of either the joint itself or associated structures Majority of patients are female Between 20 and 40 years of age Female sex hormones play a role Depression Rheumatoid arthritis Chronic fatigue syndrome Chronic headache Fibromyalgia Sleep disturbances Irritable bowel syndrome

12. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 12 Trauma Direct (assault) Indirect (whiplash injury) Resulting from parafunctional habits such as clenching or bruxism Psychosocial factors (stress) Dentofacial deformities May be associated with disorders in growth and development as in condylar hyperplasia or hypoplasia Pathophysiology of Temporomandibular Joint Disorders

13. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 13 Pathophysiology of Temporomandibular Joint Disorders Abnormalities are associated with a number of systemic diseases: Depression Rheumatoid arthritis and osteoarthritis Chronic fatigue syndrome Chronic headache Fibromyalgia Sleep disturbances Irritable bowel syndrome Female sex hormones play a role Iatrogenic cause

14. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 14 Patient Evaluation Dysfunction may be caused by disorders of muscles of mastication or by internal derangements of components of the joints Evaluation involves a comprehensive history and thorough clinical examination Chief complaint History: Chief complaint, medical, dental Examination Imaging

15. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 15 Patient Evaluation Patient management: Reduced mouth opening Shorter appointments Pain control Three cardinal features of temporomandibular disorders: Orofacial pain Joint noise Restricted jaw function

16. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 16 History Ask questions! Medical/dental history Precipitating events Circumstances that exacerbate or diminish symptoms Onset and progression of symptoms: Sudden or gradual Joint symptoms (clicking, popping) Pain Problems with mastication Trismus Malocclusion Parafunctional habits (bruxing, clenching) Extensive dental or orthodontic treatment History of surgical treatment of the jaws

17. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 17 Investigate Patient’s History Orofacial pain: What is causing it? Referral may be necessary Differential Diagnosis: TMDsPericoronitis CariesCracked tooth syndrome InfectionPulpalgia Mucosal disordersBurning mouth syndrome HeadacheNeuralgia FibromyalgiaOtitis media Sinus infectionCervical spine pain Salivary gland pathologyTumor TrismusOral surgery procedures Local anestheticFacial bone fractures Radiation therapyMedications

18. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 18 Clinical Examination Includes examination of the joint, muscles of mastication, oral cavity, and cervical spine Auscultation Palpitation Are joint noises such as clicking, crepitus, or popping related to mandibular movement? Evaluate movement of mandible in a normal rotation and translatory cycle Measure interincisal opening and note any obvious deflection to the right or left side Note lateral excursions, protrusions, deviations, and deflection Evaluate occlusion

19. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 19 Imaging Panoramic Transcranial Tomography Computed tomography Magnetic resonance imaging Arthrography

20. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 20 Imaging

21. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 21 MRI Imaging

22. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 22 Types of Temporomandibular Disorders Myofascial pain and dysfunction Internal derangements Arthritis

23. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 23 Myofascial Pain and Dysfunction A dysfunctional muscle hyperactivity with regional pain, tenderness in affected muscles, and variable amounts of reduced opening and complaints of malocclusion Comprises at least 50% of all TMDs

24. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 24 Internal Derangements An abnormal positional relationship of the disk relative to the mandibular condyle and the articular eminence Continuous pain exacerbated by jaw movement

25. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 25 Disk Displacement With reduction It may be displaced anteriorly and returns to normal position when the mouth is opened or movement is away from the affected side Without reduction It may act as an obstacle to the sliding condyle Patients may complain of problems such as intermittent locking of the jaw; a sudden onset of limited mouth opening, usually associated with cessation of joint sounds; deflection of the mandible, with a midline correction on opening; and restricted lateral excursive movements away from the affected side

26. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 26 Arthritis Inflammation of the joint Osteoarthritis Characterized by degenerative changes of the cartilage Pain symptoms that are worse in the evening Limited opening Muscle splinting Crepitus Rheumatoid arthritis An inflammatory, immunologic disorder of the joints Symptoms that are worse in the morning Limited opening Occlusal changes Preauricular edema Tenderness

27. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 27 Hypermobility Disorders Dislocation When one or both of the condyles translates anterior to the articular eminence, leading to an open lock the patient cannot reduce Subluxation Hypermobility in which the patient can relocate the mandible back into the glenoid fossa

28. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 28 Ankylosis Immobility of the condyle caused by fibrous or bony union between articulating surfaces Joint infection after trauma accounts for 50% of all cases 30% result from trauma without infection Classified by: Tissue type (fibrous, bony) Location (intraarticular, extraarticular) Extent of fusion (complete, incomplete)

29. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 29 Tumors of the Temporomandibular Joint Osteochondroma Osteoblastoma Chondroblastoma Osteoma Synovial chondromatosis: Most common benign neoplasm of the synovium Osteogenic sarcoma: Commonly occurring malignant bone tumor

30. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 30 Treatment of Temporomandibular Joint Disorders Nonsurgical treatment Surgical treatment Multidisciplinary treatment

31. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 31 Nonsurgical Treatment Goals involve improving function and reducing pain Pharmacologic therapy: Pain medication, muscle relaxants, and antianxiety agents Moist heat Physical therapy Soft mechanical diet Jaw stretching Coordination exercises Occlusal adjustments

32. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 32 Nonsurgical Treatment The second phase involves the use of occlusal appliances These may relax muscles, protect dentition, stabilize and protect the joint, and provide biofeedback by making patients aware of their bruxing habits or by relieving the load on the disk

33. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 33 Surgical Treatment Arthrocentesis  Lavaging the joint through a needle Arthroscopy  Allows direct visualization and manipulation of the joint Open joint surgery Used to perform disk reconstruction with a prosthetic device or autogenous graft Eminectomy Removal of the articular eminence of the temporal bone

34. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 34 Multidisciplinary Management Patients may require referral to specialists such as a neurologist or an otolaryngologist

35. Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 35 Discussion Questions How is normal joint function defined? What are some of the symptoms of temporomandibular disorders? What are some nonsurgical treatment methods for temporomandibular joint disorders? Surgical methods?