Temporomandibular joint disorders- i : Temporomandibular joint disorders- i Format : Format Introduction
Movements of tmj
Clinical examination of tmj
Classification of tmj disorders
Developmental defects Introduction : Introduction Slide 4: Condoyle :
Ellipsoid – Mandibular ramus
Temporal components – 6 months, 20 yrs
In radiograph of children – cortical border not seen
In adults – absence of disease cortical border seen
Layers of fibro cartilage present Mandibular fossa (Glenoid fossa) : Mandibular fossa (Glenoid fossa) Inferior aspect of the squamous
part of the temporal bone.
Anterior limit of the Mandibular fossa.
Its most inferior aspect–summit ,apex
Normal tmj – forms roof of the fossa.
Most lateral aspect of the eminence
Mandibular fossa and eminence – 3ys,
reach mature stage at 4 yrs.
All aspects of temporal - pneumatization Interarticular disk : Interarticular disk Composed of fibrous connective tissue
Condylar head and Mandibular fossa
Superior and inferior joint space
Ant band is thick
Disk is thicker medially and laterally
Medial and lateral margins blend with capsule
Thin central portions – articulating cushion b/n
Anterior band is attached to superior
Posterior band is attached to the posterior attachment
soft tissue component of tmj.
During mandible opens Posterior attachment : Posterior attachment Bilaminar zone of vascularised & innervated loose fibroelastic tissue.
Superior lamina – rich in elastin inserts
Sup.lamina stretches and allows disk to
move forward & condylar translation.
Inferior lamina – attaches to the post
aspect of the condyle.
Posterior attachment is covered by synovial membrane Slide 8: Radiographic joint space LIGAMENTS OF THE TMJ : LIGAMENTS OF THE TMJ Ligaments play an imp role
in protecting the structure.
Collagenous connective .F
Do not enter the actively
Passive restraining device There are three functional ligaments
Temporomandibur ligament Two accessory ligaments Slide 10: Collateral ligaments (Discal ligaments)
Attach the medial and lateral borders of the Articular disc to the poles of the condoyle
They are 2 in number
Ligaments are responsible for
dividing the joint mediolateraly -
Superior and inferior joint cavities.
True ligaments composed of
Thus they do not stretch and help
In hinging movement of the TMJ
Strain of these ligaments produces pain. Slide 11: Capsular ligament
Entire tmj is encompassed
Superiorly - temporal bone
Inferiorly – neck of the condoyle
Resist medial,lateral,or inferior
Forces that tend to separate
or dislocate the joint .
Significant function is to retain the synovial fluid. Slide 12: Temporomandibular ligament
Two parts – OOP and IHP
OOP- Extends from outer surface
of the Articular tubercle and zygomatic
process posterioinferiorly up to outer
surface of the condylar neck.
IHP – outer surface of Articular tubercle – lateral pole of the condoyle and posterior part of the Articular disc.
OOP- limits the drooping of condoyle
limiting the extent of mouth opening.
IHP- Limits the posterior movement of the condoyle and disc.
It protects the lat pter from over lengthening or overextension. Slide 13: Sphenomandibular ligament
Extends from spine of the sphenoid bone and extends downwards to a small bony prominence on the medial surface of the ramus of the mandible called linguala
Do not have any significant limiting effects on Mandibular movements Slide 14: Stylomandibular ligament
It arises from the styloid process and extends downward and forward to the angle and posterior border of the ramus of the mandible.
Taut when protruded
Relaxed when opened
Limits the excessive protrusive movements. Synovial fluid : Synovial fluid A small amount of straw colored viscous fluid is found in the Articular spaces
Passive volume is 1.2ml in upper joint cavity and 0.8ml in lower joint cavity.
secreted by synovial membrane
Composition- dislysate of plasma, protein and mucin
When movements are restricted becomes viscid
Phagocytic activity BLOOD SUPPLY AND NERVE SUPPLY : BLOOD SUPPLY AND NERVE SUPPLY Superficial temporal artery
Middle menengial artery
Internal menengial artery Other important arteries are
Ascending pharyngeal arteries Venous pattern is diffuse
forming Plentiful plexus around
the capsule Auriculotemporal, Messetric , branch from posterior deep temporal .nerve. ELIVATION : ELIVATION Masseter. Temporalis ,
Medial Pterygoid of both sides (Closure of mouth) DEPRESSION (opening) : DEPRESSION (opening) Is brought by lateral Pterygoid
Other muscles like digastric,
geniohyoid ,mylohyoids. PROTRUSION & RETRUSION : PROTRUSION & RETRUSION Protrusion is a movement of lower teeth
protrude forwards beyond upper teeth. Retrusion - Mandible is drawn
back wards to rest position Lateral and medial Pterygoid Posterior fibers of temporalis
Middle and deep fibers of
Masseter digastrics and geniohyoid. SIDE TO SIDE : SIDE TO SIDE Medial and lateral Pterygoid,
of each side . Acting alternately Panoramic view : Panoramic view Panoramic helps in screening any odontogenic diseases and other disorders .
Gross osseous changes in condyle may be seen. Tran cranial projection : Tran cranial projection Sagittal view of lateral aspect of condyle and temporal component.
Identify gross osseous changes on
1) lateral aspect of the joint
2) Displaced condylar fracture
3) range of motion Trans pharyngeal projection : Trans pharyngeal projection Sagittal view of the medial pole
of the condyle.
Limited diagnostic aid.
Used to visualize the erosive
Changes of condyle rather Tran orbital view : Tran orbital view It provides ant view of the tmj.
It is perpendicular to trans cranial.
Mediolateral dimension of
Articular eminence, condylar
neck , head is visible.
Condylar neck fracture Slide 26: Conventional tomography
Morphological abnormalities or erosive changes of the condylar head are suspected.
Entire condylar head is visible in Mediolateral plane .
When More information is needed about the 3 dimensional shape and internal structure of the osseous components of the joint.
Extent of ankylosis, Neoplasms ,complex fractures. Arthrography : Arthrography Hard tissue imaging should be done before.
It is a technique in which indirect image of the disk is obtained .
By injecting radiopaque contrast agent into one or both the joint spaces.
Disc function- fluoroscopic studies.
Integrity of disk attachments . Clinical examination of the joint : Clinical examination of the joint Classification : Classification 1)Developmental disorders
Condylar hyperplasia, Condylar hypoplasia, Bifid Condyle
With out reduction
4) Inflammatory disorders
Synovitis , capsulitis
Arthritis – rheumatoid arthritis, osteoarthritis , septic arthritis . Slide 30: 5) Traumatic
Ankylosis- fibrous , bony
Benign or malignant
8) Masticatory muscle disorder
Myalgia Classification : : Classification : I. Intra - Articular / intrinsic disorders :
a. Dislocation & Subluxation
c. Intracapsular #,
2. Internal disc displacement
a. Anterior disc displacement with reduction
b. Anterior disc displacement without reduction Slide 32: 3. Arthritis
b. Rheumatoid arthritis
c. Juvenile arthritis
d. Infectious arthritis
4. Development defects
a. Condylar agenesis/aplasia
b. Bifid condoyle
c. Condylar hyperplasia
d. Condylar hyerplasia
5. Ankylosis Slide 33: 6. Neoplasms
a. Begnin tumours - osteoma, osteochondroma, chondroma
b. Malignant tumors - chomdrosarcoma, fibrosarcoma,
II. Extra- Articular / extrinsic disorders
1. Masticatory muscle disorders
a. Protective muscle splinting
b. Masticatory muscle spasm
c. Masticatory muscle inflammation Slide 34: 2. Problems that result from extrinsic trauma
a. Traumatic arthritis
c. Myositis, Myospasm
d. Tendonitis Diagnostic classification : Diagnostic classification Cranial bones
Disorders Congenital and developmental
Acquired disorders (neoplasia)
Deviation in form
Ankylosis Slide 36: Masticatory –muscle
Disorders Myofacial pain
Contracture Developmental defects : Developmental defects Condylar hyperplasia
Enlargement and Occasional deformity of condylar head.
Etiology – Overactive cartilage or persistent cartilaginous rests.
Unilateral , bilateral .
C/F – Males , <20 yrs
Progress slowly or rapidly.
Patients have Mandibular asymmetry –dpending degree of condylar enlargement
Chin deviated .
Remain unaffected – increase in vertical dimension of ramus ,body of the mandible, alveolar process.
Posterior open bite – affected side. Clinical features : Clinical features Patient have symptoms Tmj dysfunction ,
c/o limited or deviated Mandibular opening or both
Condyle appear normal but symmetrically enlarged
Altered shape (conical ,spherical, elongated )
It may be more radiopaque – additional bone present.
Condylar neck may be elongated
And thickened and may be bent laterally
Cortical thickness and trabecular - normal
Glenoid fossa- enlarged
Ramus and body – Slide 39: Differential diagnosis
Combined othognathic and orthodontic can be done
after condylar growth is complete. Condylar hypoplasia : Condylar hypoplasia Failure of condyle to attain normal size
Etiology – Congenital and developmental anomalies
Condyle is small , Morphology is usually normal.
C/F – Underdeveloped ramus, body of mandible
unilateral or bilateral
(Micrognathia, TreacherCollins syndrome)
also associated with congenital defects of ear, zygomatic
Acquired abnormalities - damage during growth period.
Mandibular asymmetry ,symptoms of tmj dysfunction.
Chin deviated towards affected side.
Mandible deviated to the affected side – mouth opening Slide 41: Radiographic features
Normal shape, size is diminished.
Mandibular fossa is small
Condylar neck is slender, shortened, elongated
Ramus and body may be small – Mandibular asymmetry
Antegonial notch is deepened. Differential diagnosis
Juvenile rheumatoid arthritis Treatment
Othognathic surgery, bone grafts, orthodontic therapy Bifid condyle : Bifid condyle A bifid condyle has a vertical depression notch or deep cleft in the center of the condylar head.
Resulting in appearance of a double or bifid condylar head.
Unilateral or bilateral
Etiology – obstructed blood supply or other embryopathy, trauma
C/F: Its an incidental finding in OPG OR AP
Have signs & symptoms TM Dysfunction including
joint noise and pain.
Depression or notch is present on superior condylar surface
Heart shape appearance.
The Mandibular fossa may remodel to accommodate the altered condylar morphology. Slide 43: Differential diagnosis
Vertical fracture through the condylar head.
Not indicated until pain or functional impairment is present. Slide 44: To be continued …………
Thank you Temporomandibular joint disorders- ii : Temporomandibular joint disorders- ii Format : Format Soft tissue abnormalities
Degenerative joint diseases
Inflammatory disorders of tmj
Tumours of tmj
Miscellaneous disorders Soft tissue abnormalities : Soft tissue abnormalities Internal derangements
Abnormality in the position and morphology.
Disk most often displaced in anterior direction.
Hypothesize – normal variant
Aetiology – Parafunction ,jaw injuries , whiplash injury and forced opening.
Diagnosis – Arthrography or MRI .
Clinical features – Symptomatic patients & healthy.
Symptomatic pt – decreased mand motion.
Unilateral or bilateral .
Unilateral - Mand deviation to affected side, joint noise,
Noise may be absent in chronically displaced non reducing disks
Pain , Episodes of closed or open locking of joint. Disk displacement : Disk displacement Ant disk displacement – Most common.
Disk displacement with reduction
Retrodiscal lamina and Discal collateral ligaments become further elongated & post fibers thinned.
Disc can slip or be forced – Discal space
Since disc and condyle do not articulate – Dislocation
If patient can manipulate jaw to reposition condyle– said to reduced.
Clinical features :
Unless jaw is reduced- limited mouth opening
Clicking or popping sounds during Mandibular opening.
Opening click , Closing click, reciprocal clicking.
Deviation of the mand midline – characteristic finding .
If pain accompanies ADD – Strained Discal ligaments. Management : Management Ant Repositioning therapy- Ant Repositioning splint therapy.
Pain and clicking reduced.
Joint stabilization – Max joint stabilization splint. Disc displacement without reduction : Disc displacement without reduction Condition is characterized by displacement of the disc on closing followed by a failure to reduce or recapture the disc during translation.
Elasticity of the sup Retrodiscal lamina is lost
Condyle is unable to pass under displaced disc.
Contact is lost
Clinical signs and symptoms
Severely restricted opening of max 25-30 mm
Mandibular midline deflecting to side of involved joint.
Protrusive and lateral movements restricted.
Painful due to inflammation in capsule, ligaments.
Clicking not seen in acute , but present in chronic stage.
Limited mouth opening – Elevator muscle spasm. Management : Management Acute stage- reducing the displaced disc – manual mobilization
Prior to mobilization – NSAIDS , Muscle relaxants , Block
Ant repositioning splint – Immediately in max arch.
Full time 10 days- soft diet
After 10 days – reduced – repositioning splint – maxillary splint for night for 2 months
Converted into joint stabilization splint. Degenerative joint disease : Degenerative joint disease Osteoarthritis: (osteoarthrosis,degenerative arthritis)
Non inflammatory disorder of joints characterized by Joint deterioration and proliferation.
Joint deterioration is characterized by abrasion, loss of Articular cartilage & bone erosion.
Mild over loading may lead to this condition
Excessive pressure – Degeneration of fibrous articular tissues
Elastic compressibility – fibrous cartilage.
Proliferative component is characterized – New bone formation at articular surface in the Subchondral region
Combination of deterioration and proliferation occur. Slide 54: Aetiology – Acute trauma, hypermobility,
Clinical signs and symptoms
Any age, increases with age. > females.
Absence of pain. Tmj dysfunction.
Lack of point tenderness in the joint on palpation.
Limited movement of jaw with deflection.
Crepitus – heard in later stage of disease.
Onset of symptoms may be sudden or gradual.
Studies reports – burns out. Radiographic feature Max intercuspation- joint space –absent Flattening and Subchondral sclerosisloss of cortex or erosions – articulating surface of condyle or temporal comp.small round radiolucent areas with Irregular margins surrounded varyingarea of increased density – deep to articulating surfaces- Ely-cystsOsteophytes–new bone ant sup condyleOsteophytes may break – joint mice. : Radiographic feature Max intercuspation- joint space –absent Flattening and Subchondral sclerosisloss of cortex or erosions – articulating surface of condyle or temporal comp.small round radiolucent areas with Irregular margins surrounded varyingarea of increased density – deep to articulating surfaces- Ely-cystsOsteophytes–new bone ant sup condyleOsteophytes may break – joint mice. Slide 56: Differential diagnosis
Osteoma , osteochondroma
Relieving joint stress ( splint therapy)
Relieving secondary inflammation – anti-inflammatory.
Corticosteroids. Slide 57: Arthritis
Multiple joints of the body, Systemic disorder.
Inflammation of the synovial membranes.
As force is placed on these surfaces,
In severe cases osseous tissues are resorbed.
More commonly associated with joint of hands ,wrist,
Also occur in tmj ,always bilateral
h/o multiple joint complaint,- diagnostic
Condylar support lost- malocclusion
Diagnosis confirmed – blood studies.
Villous synovitis –
synovial granlomatous tissue (pannus) Slide 58: Clinical features
> Females , at any age, increases with age.
Small joints of hand, wrist , feet ,knees, affected in bilateral symmetric fashion.
Tmj involvement – swelling , pain ,tenderness, stiffness on opening , limited range of motion and crepitus.
Generalized osteopenia of condyle & temp component.
Pannus destroy disk – diminished width of joint space
Erosions of the anterior and posterior condylar surfaces
sharpened pencil appearance.
Erosive changes are severe that condylar head -
destroyed, only neck remaining as articulating surface Slide 59: Subchondral sclerosis and flattening of articulating surface may occur – Subchondral cyst & osteophyte Slide 60: Differential diagnosis
Definitive treatment – No treatment
Supportive treatment- a) Pain reduction ,
b) Stabilization appliances -- decrease force art surfaces.
c) Occlusion is closely monitored – occlusal changes
d) Joint replacement surgery Juvenile chronic arthritis (Stills disease) : Juvenile chronic arthritis (Stills disease) Is a chronic inflammatory disease that appears before age of 16 yrs ( mean age 5 yrs).
Chronic intermittent synovial inflammation – synovial hypertrophy, joint effusion, swollen & painful joint.
As disease progresses- cartilage and bone are destroyed.
Rh factor is absent.
JCA differs from RA
TMJ involvement – 40%
Unilateral or bilateral .
Patient has pain, tenderness in affected joint,
Disease can be asymptomatic. Unilateral. Slide 62: Clinical features
Contralateral involvement is seen as disease progresses
Severe Tmj involvement – inhibition of mand growth.
Affected patients- micrognathia , Bird faces.
Accompanied by ant open bite.
Degree of micrognathia – Proportional to the severity
Osteopenia of affected joint-
Erosion extends to mand fossa.
Art eminence destroyed.
Erosions of the ant or sup
aspect of the condyle may occur. Slide 63: Severe cases pencil shaped condyle remains ,condyle may be destroyed.
Hypomobility at max opening is common
Fibrous ankylosis is common
Sec degenerative changes – Sclerosis , Osteophyte
Inhibited Mandibular growth. Infectious arthritis (Septic arthritis) : Infectious arthritis (Septic arthritis) Is infection and inflammation of the joint, rare.
Bacterial infection may invade the TMJ.
Caused by direct spread of organisms.
Direct extension of osteomyelitis of mandible.
Hematogeneous spread – common,
Middle ear infection.
Any age ,no gender predilection.
Redness and swelling over the joint.
Trismus, severe pain on opening mouth. Unilateral .
Inability to occlude the teeth, large, tender cervicalnodes
Fever malaise, mandible deviated to unaffected side. Radiographic features : Radiographic features Early stages of disease – no radiographic signs may be present.
Space b/n condyle and mand fossa widened
Osteopenic changes of joint components & mand components are evident.
Evident bony changes – 7-10 days after clinical symptoms.
Condylar Articular cortex may be radiolucent.
Osseous ankylosis – after infection subsides.
If disease occur during mand growth – inhibited mand growth. Slide 66: Differential diagnosis
Drainage of effusion , joint rest
Physiotherapy Psoriatic arthritis : Psoriatic arthritis Is an inflammatory condition affects 6% of patients with psoriasis.
1.2% general population
Patient gives h/o chronic skin lesions- diagnosis
Clinically resembles RA but serological studies –ve
Radiographic findings of osteoarthritis are common
Definitive treatment : No definitive treatment
Supportive treatment: NSAIDS
physiotherapy, heat , ultrasound therapy. Ankylosing spondilytis(marie strumpell disease) : Ankylosing spondilytis(marie strumpell disease) Is a chronic inflammatory connective tissue disease that
affects axial skeleton and central joints including TMJ.
Primarily affects the vertebral column.
1% of general population is affected
TMJ involved in 4% , > men
Generalized stiffens of the joint.
Should suspect this condition-
Flattening of the Articular surface of tmj
Osteophytic formation is common
Erosion of condylar head is common
Management Gout : Gout Dietary changes can lead to hypurecemia commonly called gout
It is a chronic metabolic disorder characterized by acute exacerbation of joint pain and swelling associated elevated blood uric acid and deposition of crystals of monosodium urate.
When high levels of serum uric acid persists
Acute gout arthritis
Chronic gout arthritis
Thiazide diuretics , operations , trauma, alcohol, weight loss Metabolic Slide 70: Clinical features
Older persons, Bilateral .
Sudden excruciating pain in TMJ followed by rapid swelling.
Tenderness of the affected area with limited movement
Deviation to affected side on opening.
Dietary changes may aggravate symptoms.
Blood studies , uric acid studies.
Punched out areas- carpal bones
Punched out radiolucency – condylar cartilage
Severe distruction – cartilage
Colchicne .5mg 2 hourly Synovitis or capsulitis : Synovitis or capsulitis An inflammation of the synovial tissues (synovitis) and of the capsular ligament (capsulitis).
Differentiated by arthroscopy.
Trauma to the tissue, such as macro trauma (a blow to the chin)
Micro trauma (a slow impingement on these tissues by posterior condylar displacement).
Wide-open mouth procedures or abusive movements.
Inflammation spreads from adjacent structures.
Capsular ligament can be palpated - finger pressure over the lateral pole of the condyle. Inflammatory disorders of the joint Slide 72: Pain in preauricular area.
Limited Mandibular opening secondary to pain is common.
If edema from the inflammation is present, the condyle may be displaced interiorly.
Creates a disocclusion of the
ipsilateral posterior teeth.
Restrict mand movements.
Soft diet and slow movements.
Constant pain- NSAIDS
Thermotherapy of joint area.
Ultrasound therapy Retrodiscitis : Retrodiscitis An inflammatory condition of the Retrodiscal tissues.
Usually trauma. Extrinsic and intrinsic.
Extrinsic trauma is created by a sudden movement of the condyle into the Retrodiscal tissues.
However, with both severe and mild trauma
the possibility exists that the condyle
will be momentarily forced into the
These tissues often respond to this type
of trauma with inflammation.- swelling.
Condyle moves forward- acute malocclusion.
Inability to bite in posterior teeth Slide 74: Intrinsic trauma to the Retrodiscal tissues - anterior functional displacement or dislocation of disc.
Intrinsic trauma – inflammation of Retrodiscal tissues
Clenching teeth – increases pain.
If the tissues swell, a loss of posterior occlusal contact can occur on the ipsilateral side.
Careful observation of the occlusal condition.
No evidence of acute malocclusion - analgesics for pain
instructed to restrict movement to within painless limits
Ultrasound and thermotherapy
If pain persists single intracapsular injection of corticosteroids.
As symptoms resolve, the reestablishment of normal Mandibular.
Malocclusion – Stabilization type appliance . Traumatic disorders of tmj : Traumatic disorders of tmj EFFUSION
Effusion is an influx of fluid into the joint, usually as a result of trauma(haemorrage) or inflamation(exudate).
Swelling over the affected joint;
Pain in the TMJ, preauricular region, or ear;
limited range of motion.
Sensation of fluid in the ear, tinnitus, and hearing difficulties.
Difficulty occluding the posterior teeth. Radiographic Features : Radiographic Features Joint effusion is more commonly seen in conjunction with internal derangements.
Although it has been described in normal joints.
The joint space will be widened,
T2-weighted MRI studies may show a bright signal (white), indicating fluid adjacent to the disk or posterior to the condyle .
Surgical drainage , Anti-inflammatory drugs Dislocation : Dislocation Dislocation is abnormal positioning of the condyle out of the Mandibular fossa but within the joint capsule.
Commonly in an anterior direction.
Dislocation may be caused by a failure of muscular coordination, Subluxation, or external trauma and may be associated with a condylar fracture.
Patients are unable to close the mandible to maximal
Some patients cannot reduce the dislocation. Radiographic Features : Radiographic Features Both condyle are located anterior and superior to the summits of the articular eminence.
Manual manipulation of the mandible to reduce the dislocation.
Surgery occasionally needed . FRACTURE : FRACTURE Fractures of the TMJ usually occur at the condylar neck and often are accompanied by dislocation of the condylar head.
Divided into those involving the
Both may be involved.
Unilateral fractures - common than Bilateral
Accompanied by a parasymphyseal or Mandibular body fracture on the Contralateral side.
limited range of motion, and an anterior open bite.
Pain at tmj, swelling .
Some TMJ fractures - asymptomatic
Condylar fractures should be ruled out – Blow to ant aspect of mand. Radiographic Features : Radiographic Features Radiolucent line outline of the neck.
This line may vary in width, depending on whether the bone fragments are still aligned (narrow line) or displacement/dislocation has occurred (wider line).
Condyle – remodeling to form bifid condyle
Condyle undergoes degenerative changes.
Not indicated if Mandibular mobility is adequate
Otherwise, the fracture is reduced surgically Ankylosis : Ankylosis Ankylosis is a condition in which condylar movement is limited by a mechanical problem in the joint
Mechanical cause not related to joint components.
True ankylosis may be bony or fibrous.
In bony ankylosis the condyle or ramus is attached to the temporal bone by an osseous bridge.
In fibrous ankylosis a soft tissue union of joint components occurs the bone components are normal.
False ankylosis - Muscle spasm, Myositis ossificans, coronoid process hyperplasia. Slide 82: Clinical Features
Caused by Mandibular trauma or infection.
Restricted jaw opening,
long-standing history of limited opening.
Mandibular opening usually is possible through flexing of the mandible.
Asymmetry of the face.
Unilateral – to affected side, cross bite
Bilateral – symmetrical ,micrognathia , no gliding mts
class 2 malocclusion, Radiographic Features : Radiographic Features Fibrous ankylosis - Osseous components of the joint may appear normal or articulating surfaces – irregular
Joint space is markedly decreased.
Little or no condylar movement is seen.
Radiographic signs of remodeling
Bony ankylosis- Joint space may be partly or completely obliterated - osseous bridge
This new bone may fuse the condyle
to the cranial base
Secondary degenerative changes of the joint components are common. Slide 84: Morphologic changes - Elongation of the coronoid processes
Deepening of the Antegonial notch in the Mandibular ramus.
If ankylosis occurs before Mandibular growth is complete.
Joint mobility is improved by surgical removal of the osseous bridge.
Creation of a pseudarthrosis. Tumors : Tumors Benign and malignant tumors TMJ - Rare.
Intrinsic or extrinsic
Intrinsic tumors may develop in the condyle, temporal bone, or coronoid process.
Extrinsic tumors may affect the morphology, structure, or function of the joint without invading the joint itself. BENIGN TUMORS
The most common benign intrinsic tumors
Benign giant cell lesions,
Aneurysmal bone cysts. Slide 86: Benign tumors and cysts of mandible.
Simple bone cyst
Tmj swelling , accompanied by pain ,
Decreased range of motion ,
Facial asymmetry ,
Deviation of mandible to unaffected side
Condylar enlargement that often irregular outline
Trabecular pattern – altered - Radiolucency
New abnormal bone formation - Radiopacites Slide 87: An osteoma or osteochondroma appears as abnormal
Pedunculated mass attached to condyle.
Tumor interfere with joint function
Surgical excision of tumor
Excision of condylar head Malignant tumors : Malignant tumors Malignant tumors of condyle are rare.
Chomdrosarcoma, osteogenic sarcoma, synovial sarcoma, Fibrosarcoma of joint capsule.
Extrinsic malignant tumors
Direct extension of adjacent parotid salivary malignancies.
Regional carcinomas – skin ear and nasopharynx
Most common metastatic tumor
Brest ,kidney, colon, prostate, thyroid, Slide 89: Clinical features
17 months to 68yrs
Asymptomatic or patients may have symptoms
Tmj pain limited Mandibular opening
Mandibular deviation – unaffected side.
Variable degree of bone distruction- irregular margins.
Radiolucent destructive lesion of condyle with surrounding soft tissue calcification
Metastatic tumors- nonspecific condylar destruction Differential diagnosis : Differential diagnosis DJD
Primary malignant tumors -surgical removal of the
Metastatic tumors rarely are treated surgically.
Radiotherapy and chemotherapy. SYNOVIAL CHONDROMATOSIS : SYNOVIAL CHONDROMATOSIS (Synovial chondrometaplasia and osteochondromatosis)
Synovial chondromatosis is an uncommon disorder characterized by metaplastic formation of multiple cartilaginous and osteocartilaginous nodules within connective tissue of the synovial membrane of joints.
Some of these nodules may detach and form loose bodies in the joint space may increase in size.
More common in the axial skeleton than in the TMJ
Asymptomatic or may complain of preauricular swelling, pain, and decreased range of motion.
crepitus or other joint noises.
Unilateral. Miscellaneous disorders Radiographic Features : Radiographic Features The osseous components may appear normal or may exhibit osseous changes similar to those in DJD.
The joint space may be widened.
CT imaging can identify the location of the calcifications.
Occasionally erosion through the Glenoid fossa into the middle cranial fossa may occur.
Removal of loose bodies CHONDROCALCINOSIS : CHONDROCALCINOSIS (Pseudogout and calcium Pyrophosphate dihydrate
Chondrocalcinosis is characterized by acute or chronic synovitis and precipitation of calcium pyrophosphate dihydrate crystals in the joint space.
The joints more commonly affected are the knee, wrist, hip, shoulder, and elbow.
TMJ involvement is uncommon.
unilaterally and is more in males.
Patients may be asymptomatic or may complain of pain and joint swelling. Radiographic Features : Radiographic Features The radiographic appearance of Chondrocalcinosis may simulate synovial chondromatosis.
Bone erosions are present ,increase in condylar bone density.
Erosions of the Glenoid fossa may be, which require CT for detection.
Surgical removal of the crystalline deposits.
Steroids, and Non steroidal anti inflammatory agents may provide relief. Conclusion : Conclusion Slide 96: Thank you