Classification of Diseases of TMJ

Developmental disturbances of TMJ: Aplasia of mandibular condyle Hyperplasia of mandibular condyle Hypoplasia of mandibular condyle Truamatic disturbances of TMJ: Luxation & Subluxation Ankylosis Injuries of articular disc Fracture of condyle Inflammatory disturbances of TMJ: Arthritis due to specific infection Rheumatoid arthritis Osteoarthritis Traumatic arthritis Neoplastic disturbances of TMJ: Ossifying fibroma Osteoma Osteoblastoma Osteoid osteoma chondroma

Osteosarcoma Chondrosarcoma Ewings sacoma Metastatic tumors Extraarticular disturbances of TMJ: Impacted molar teeth Sinusitis Middle ear disease Infratemporal cellulitis Impingement of coronoid process on tendon of temporal muscle Neuritis of third division of 5th cranial nerve Odontalgia Foreign body in infratemporal fossa Overclosure of mandible accompanied by severe dental attrition Costens syndrome Myofascial pain-dysfunction syndrome

Luxation & Subluxation

(complete & incomplete dislocation) Dislocation of TMJ: occurs when head of condyle moves anteriorly over articular eminence into such a position that it cannot be returned voluntarily to its normal position. spasm of temporal muscle Luxation of joint: refers to complete dislocation Subluxation: is a partial or incomplete dislocation, actually form of hypermobility

Subluxation:
When condyle is obviously outside limits of normal in its position, joint is actually dislocated No abnormal joint relation visible on temporomandibular roentgenogram

Though condyle may lie well anterior to articular eminence, such position is normal for many persons

Luxation:
Traumatic injury resulting fracture of condyle Stretching of capsule Mouth opened too widely Yawning Dentist extracting teeth Physician removing tonsils Injudious use of mouth prop Clinical features: Sudden locking & immobilization of jaws when mouth is open Prolonged spasmodic contraction of temporal, internal pterygoid & masseter muscles Protrusion of jaw Eating or talking are impossible Mouth cannot be closed Patient becomes frequently panicky, especially if it is his first experience Superior & posterior dislocation of condyle Rare & as result of acute traumatic impaction injury Head of condyle forced through glenoid fossa or tympanic plate into middle cranial fossa Treatment: In some instances patient may be able to reduce dislocation himself ( in chronic dislocation when ligaments become stretched) Inducing relaxation of muscles Guiding head of condyle under articular eminence into its normal position by an inferior & posterior pressure of thumbs in mandibular molar area

Ankylosis (Hypomobility)
Fibrous or bony union between articular surfaces of joint Etiology: Traumatic injuries Infections in & about joint According to Topazian 49% joint inflammation 31% trauma Remaining idiopathic

Traumatic injuries: Abnormal intrauterine development Birth injury (by forceps particularly) Trauma to chin forcing condyle against glenoid fossa Malunion of condylar fractures Injuries associated with fractures of malar-zygomatic compound Loss of tissue with scarring Congenital syphilis Infections in & about joint: Primary inflammation of joint (rheumatoid arthritis, infectious arthritis, Marie-Strumpell disease) Inflammation of joint secondary to local inflammatory process (otitis media, mastoiditis, osteomyelitis of temporal bone or condyle) Inflammation of joint secondary to blood stream infection (septicemia, scarlet fever) Metastatic malignancies Inflammation secondary to radiation therapy

Clinical features: Most cases occur before age of 10 years Equal distribution between sexes May or may not be able to open mouth depending on type of ankylosis Fibrous ankylosis: some motion is possible Bony ankylosis: absolute limitation of motion Unilateral or bilateral ankylosis Facial deformity Unilateral ankylosis: If occuring at early age Chin is displaced laterally & backward on affected side Because of failure of development of mandible

When attempt is made to open mouth, chin deviates toward ankylosed side, if any motion is present Bilateral ankylosis: Childhood Underdevelopment of lower portion of face Receding chin & micrognathia Maxillary incisors often manifest overjet

TMJ ankylosis
Intra-articular ankylosis: Progressive destruction of meniscus Flattening of mandibular fossa Thickening of head of condyle Narrowing of joint space Ankylosis is basically fibrous---bony

Extra-articular ankylosis: -splinting of TMJ by fibrous or bony mass external to joint proper -in cases of infection in surrounding bone or extensive tissue destruction

Movement is possible in extra-artcular ankylosis but there is no movement in intra-articular ankylosis, especially of bilateral type Roentgenographic features: Abnormal or irregular shape of head of condyle Radiopacity indicative of dense bone filling joint space

Treatment: Bony ankylosis: osteotomy or removal of section of bone below condyle Fibrous ankylosis: functional methods

Rheumatoid arthritis
Hypersensitivity reaction to bacterial toxins, specifically streptococci Nearly always polyarticular & frequently symmetrically bilateral Episodic exacerbations & remissions TMJ involvement is not common (20%)

Clinical features: Early adult life Affects women In its early stages- slight fever, loss of weight & fatigability Joints affected are swollen Patient complains of pain & stiffness Stiffness is commonly in morning & tends to diminish throughout day with continued use of jaw Marie-Strumpell type of rheumatoid arthritis TMJ is frequently involved Usually sole involvement of spine, sacroiliac & hip joint

Stills disease: Rheumatoid arthritis in children Malocclusion of class II division 1 type Protrusion of maxillary incisors & anterior open bite Shortening of body & reduction in height of ramus Radiographs revealed flattening & stunting of condyles & haziness about joint indicative of periarticular fibrosis

Histologic features: Ingrowth of granulation tissue to cover articular surface Invasion of cartilage & its replacement by granulation tissuedestruction of articular cartilage meniscus may become eroded Fibrous ankylosis---ossification---bony ankylosis

Treatment: No specific treatment

ACTH or cortisone Condylectomy: limitation of motion & deformity Great tendency for recurrence of ankylosis

Extra-articular disturbances of TMJ

Extra-articular disturbances of TMJ: Manifest clinically as TMJ problems Prevent examiner from arriving at correct diagnosis Most common presenting complaint is pain in TMJ (referred pain) Costens syndrome: Producing symptoms referable in part to TMJ Impaired hearing, tinnitus, facial & temporal neuralgia, otalgia & glassodynia TMJ dysfunction has usually been considered basic disturbance leading to these symptoms

Myofascial Pain-Dysfunction Syndrome

Also k/s Temporomandibular joint pain dysfunction syndrome Masticatory myalgesia syndrome Dysfunction of entire masticatory apparatus Certain psychologic characteristics Etiology: Masticatory muscle spasm Muscular overextension Muscular overcontraction Muscle fatigue Muscular overextension:

Dental restorations Prosthetic appliances Which encroach on intermaxillary space Muscular overcontraction: result of overclosure Bilateral loss of posterior teeth Continued resorption of alveolar bone after construction of prosthetic appliance Muscle fatigue: Chronic oral habits as grinding or clenching of teeth Result from irritating factors such as improperly occluding restoration or overhanging margin on restoration Involuntary tension-relieving mechanism involving emotional as well as mechanical factor (psycho-physiologic theory)

Masticatory muscle spasm -> Pain & limitation of motion ->Minor shift in jaw rest position ->Teeth do not occlude properly Clinical features: Four cardinal signs & symptoms Pain Muscle tenderness Clicking or popping noise in TMJ Limitation of jaw motion, unilaterally or bilaterally sometimes with deviation on opening Two typical negative disease characteristics Absence of clinical, roentgenographic or biochemical evidence of organic changes in joint itself Lack of tenderness in joint when it is palpated through the external auditory meatus Psychologic or psychogenic component: 80% gave history of other psychophysilogic diseases Such as gastrointestinal ulcer, migraine headache or dermatitis

Higher excretion levels of 17-OH steroids & catecholamines which have been linked to stress phenomenon

Treatment: Conservative Relief of emotional factors Correction of faulty restorations & appliances Myotherapeutic exercises & phsiotherapy & drug therapy ( tranquilizers & muscle relaxants)