4- Treating TMJ disorders

How are TMJ disorders categorised in 4 groups? (Treatment depends on which category)

1- alterations of condyle disc complex

• displacements and dislocations (with/out reduction)

2- structural incompatibility

• morphological alterations

• adhesions

• subluxation

• spontaneous dislocation

4- inflammatory disorders

• synovitis/capsulitis

• retrodiscitis

• arthritis

5- associated structures

• temporal tendinitis

• stylomandibular ligament

What is disc displacement with reduction- define, etiology, causal factors, diagnosis?

Initial phase of disc alteration- condyle recovers position on disc during opening

Elongation of discal/capsular ligaments and thinning of intermediate zone of disc

Direct or chronic microtrauma (hypoxia-reperfusion, bruxism)

Normal mandibular range of motion, pathological prescience of reciprocal joint noise (click)

How to treat disc displacement?

Re-establish condyle-disc relationship to eliminate painful load

Orthopaedic technique- anterior repositioning device- eliminates click

Mainly use at night to promote tissue adaption without altering occlusion permanently

Therapies- voluntary movement restrictions soft diet and temp analgesia

How can morphological alteration of adhesions cause structural incompatibility?

Morphological changes to smooth surface of disc or bony structures due to trauma or chronic overload

Temporary union (simple adhesion) or permanent (fibrotic ct) between articular surfaces

What is the etiology, clinical manifestation and invasive treatment of structural incompatibility?

Post macrotrauma hemarthrosis or prolonged static loading (eccentric bruxism/clenching)

Single, dry click when opening (temp adhesion) or severe limited opening without noises

Manually manipulate under anesthesia, arthrocentesis or arthroscopy of conservative management fails

What is subluxation?

Sudden displacement of condyle anterior to eminence

Causes dull sound (thud) at end of MO

can do opposing exercises, intraoral limiters and voluntary restriction

What is spontaneous dislocation?

Mandible locks in full opening, closure impossible

Very painful due to elevator muscle spasm

Firm continuous downward pressure on lower molars then a gentle backward push treats it

What is synovitis and cpasulitis?

Canst distinguish between these without arthroscopic access

Inflammation of synovial intima or capsular ligament

Due to single macro trauma (direct blow to chin) or many micro traumas from muscle hyperactivity

What is the biomechanical diagnosis of synovitis and capsulitis, clinical palpation and treatment protocol?

Continuous pain exaggerated only by elongating the capsular ligament (at MO or translation)

Acute pain just anterior to tragus and at lateral pole of condyle

Soft diet, schedules NSAIDs, thermotherapy (moist heat) and ultrasound

What is retrodiscitis?

Inflammation off retro disc tissue related to suppression of TMJ cavity

Diagnostic key- severe edema in retrodiscal space pushes condyle down and forwards- causes acute loss of ipsilateral posterior occlusal contact (malocclusion)

Extrinsic etiology- trauma (whiplash or blow to chin) impacts condyles into posterior zone

Intrinsic- chronic anterior disc dislocation, condyle repeatedly compresses retrodiscal bed

Treat- temp stabilisation appliance to offload tissue (extrinsic) or anterior repositioning device (intrinsic)

What is osteoarthritis- degenerative arthropathy- define, etiology, clinical symptoms, x ray, management?

Destructive disorder of subarticularbone and articular surfaces- not mainly inflam initially

Chronic overload (freq dislocations) excess capacity for cellular adaptation

Unilateral joint pain (worsens at end of day), crepitus (sand like noise) and soft end feel

Severely flat condyle, osteophyte (lipping) formation and cortical erosion

Radical reduction of mechanical load via occlusal appliances, soft diet and NSAIDs

What are the 3 natural self limiting stages of osteoarthritis?

1- click/joint lock

2- rigid lock + acute pain

3- fibrotic adaptation (pain stops, crepitus persists, opening recovers)

What is infectious arthritis?

Barrial invasion via penetrating trauma or adjacent extension, needs ATB

What is Hyperuricemia (gout)?

Precipitation of monosodium urate crystals, DD via serum analysis

What is rheumatoid arthritis?

Systemic AI disease, aggressive, bilateral presentation in TMJ

How do you treat systemic polyarthritic disorders in TMJ?

NSAIDS

Localised heat

Muscle relaxation

Must refer to rheumatology

Contraindications- correcting open bite with orthodontics during acute phases

Difference between osteoarthritis and rheumatoid polyarthiritis

What is temporal tendinitis? (DD)

Inflammation of distal insertion of temporal muscle on coronoid process

Secondary to hyperactivity (bruxism)

Causes referred retro orbital pain

Direct intraoral palpation produces sharp pain

Treat- maxillary rest, control parafunctions with splints and analgesics

What is the stylomandibular liagment?(DD)

Chronic inflammation of ligament

Pain at mandibular angle radiating to ear

Worsens with protrusive movements

Treat- maxillary rest, control parafunctions with splints and analgesics

A diagnostic block injecting LA without vasoconstrictor into muscular/ligament insertion will relieve symptoms

Clinical considerations in acute trauma- initial triage, conservative vs acute management and mechanical support?

Radiographs (opg or transcranial) to rule out maxilofacial or condylar fractures

Soft diet, total restricted mastication for 2 weeks, no aggressive pharmacological intervention

Repeated cryotherapy (first 24-36 hrs) for vasoconstriction , then thermatherapy to remove exudates