Temopromandibular joint disorders 16.5.0

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Presentation Transcript

Temporomandibular joint disorders- i : 

Temporomandibular joint disorders- i

Format : 

Format Introduction Anatomy Movements of tmj Diagnostic radiographs Clinical examination of tmj Classification of tmj disorders Developmental defects

Introduction : 

Introduction

Slide 4: 

Condoyle : Ellipsoid – Mandibular ramus M-l, A-P Shape Extreme aspects Mandibular and 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. Composed Articular eminence Anterior limit of the Mandibular fossa. Shape. Its most inferior aspect–summit ,apex Normal tmj – forms roof of the fossa. S shape 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 Shape 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 Collateral ligament Capsular ligament 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 Function 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 Function Lubricates Nutritional fluid 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 Deep auricular Anterior tympanic 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 . Computed tomography 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. Indication Disk position Function Morphology 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 2)Disc displacement With reduction With out reduction 3)Structural incompatibilities Adhesion Subluxation Dislocation 4) Inflammatory disorders Synovitis , capsulitis Arthritis – rheumatoid arthritis, osteoarthritis , septic arthritis .

Slide 30: 

5) Traumatic Fracture Ankylosis- fibrous , bony 6) Metabolic Gout 7)Tumors Benign or malignant 8) Masticatory muscle disorder Myositis Myospasm Myalgia

Classification : : 

Classification : I. Intra - Articular / intrinsic disorders : 1. Trauma a. Dislocation & Subluxation b. Haemarthrosis c. Intracapsular #, 2. Internal disc displacement a. Anterior disc displacement with reduction b. Anterior disc displacement without reduction

Slide 32: 

3. Arthritis a. Osteoarthritis 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, synovial sarcoma 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 b. Fracture c. Myositis, Myospasm d. Tendonitis

Diagnostic classification : 

Diagnostic classification Cranial bones Temporomandibular Disorders Congenital and developmental Acquired disorders (neoplasia) Deviation in form Disk displacement Dislocation Inflammatory condition Arthritis Ankylosis

Slide 36: 

Masticatory –muscle Disorders Myofacial pain Myositis Spasm Protective splinting 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 Self limiting. 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 Radiologic features 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 Osteochondroma Treatment 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 Acquired diseases 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 Occasionally crowding 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. Radiographic features 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. Treatment 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 Arthritis Inflammatory disorders of tmj Metabolic Trauma 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, Parafunction. 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. Muscle spasm 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 Rheumatoid arthritis Osteoma , osteochondroma Treatment Relieving joint stress ( splint therapy) Relieving secondary inflammation – anti-inflammatory. Physiotherapy. Myotherapy. Corticosteroids.

Slide 57: 

Arthritis Rheumatoid 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. Radiographic features 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 Psoriatic arthritis Management 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 . Clinical features 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 Radiographic features 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. Aetiology Caused by direct spread of organisms. Direct extension of osteomyelitis of mandible. Hematogeneous spread – common, Middle ear infection. Clinical features 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. Disease progress- Osseous ankylosis – after infection subsides. If disease occur during mand growth – inhibited mand growth.

Slide 66: 

Differential diagnosis DJD, RA Management Definitive treatment: Antibiotic medication Drainage of effusion , joint rest Supportive treatment 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 Management 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- Radiographic features 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 Classification Acute gout arthritis Chronic gout arthritis Predisposing factors 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. Radiographic appearance Punched out areas- carpal bones Punched out radiolucency – condylar cartilage Severe distruction – cartilage Management 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. Etiology 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. Clinical features 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. Management 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. Etiology 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 Retrodiscal tissues. 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 Clinical features Preauricular pain Clenching teeth – increases pain. If the tissues swell, a loss of posterior occlusal contact can occur on the ipsilateral side. Management 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). Clinical Features 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 . Differential Diagnosis Septic arthritis Management Surgical drainage , Anti-inflammatory drugs

Dislocation : 

Dislocation Dislocation is abnormal positioning of the condyle out of the Mandibular fossa but within the joint capsule. Bilateral. 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. Clinical Features Patients are unable to close the mandible to maximal intercuspation. Some patients cannot reduce the dislocation.

Radiographic Features : 

Radiographic Features Both condyle are located anterior and superior to the summits of the articular eminence. Differential Diagnosis Fracture condoyle. Treatment 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 Condylar head Condylar neck, Both may be involved. Temporal component. Clinical Features 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. Treatment 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. Differential Diagnosis condylar tumor. Management 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 Osteoma, Osteochondroma, Osteoblastomas. Chondroblastomas, Fibromyxomas, Benign giant cell lesions, Aneurysmal bone cysts.

Slide 86: 

Benign tumors and cysts of mandible. Ameloblastoma OKC Simple bone cyst Clinical features Tmj swelling , accompanied by pain , Decreased range of motion , Facial asymmetry , Malocclusion Deviation of mandible to unaffected side Radiographic features 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 Differential diagnosis Condylar hyperplasia Treatment 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. Rabdomyosarcoma 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. Swelling Radiographic features 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 Chomdrosarcoma Management Primary malignant tumors -surgical removal of the tumor. 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 Clinical Features 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. Differential Diagnosis Chondrocalcinosis. Chondrosarcoma. Osteochondromatosis. Treatment Removal of loose bodies

CHONDROCALCINOSIS : 

CHONDROCALCINOSIS (Pseudogout and calcium Pyrophosphate dihydrate deposition disease) Chondrocalcinosis is characterized by acute or chronic synovitis and precipitation of calcium pyrophosphate dihydrate crystals in the joint space. Clinical Features 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. Differential Diagnosis Synovial chondromatosis Treatment Surgical removal of the crystalline deposits. Steroids, and Non steroidal anti inflammatory agents may provide relief.

Conclusion : 

Conclusion

Slide 96: 

Thank you