Vinnitsya national pirogov memorial



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MINISTRY of PUBLIC HEALTH of UKRAINE

VINNITSYA NATIONAL PIROGOV MEMORIAL

MEDICAL UNIVERSITY
It is "confirmed"

on a methodical meeting of

department of pediatric dentistry

head-chair

doc.Filimonov Yu.V._____


" in20


Methodical recommendation for 4d year students

of dental faculty

Educational discipline

Pediatric surgery

Module ¹

1

Rich in content module ¹

1

Topic

Acute diseases of temporomandibular joint (arthritis), disorders and management.

Course

4

Faculty

Dental

Autor

Isakova N.M.

Vinnitsya 2012



Actuality of theme .

Among disorders of TMJ first place belongs to processes of inflamatory origin of various nature –specific, non specific, traumatic, non infectious, which can have acute or chronic course .In acute arthritis all components of acute inflamation both local and systemic –altered blood count,systemic immune response ..etc are observed.

Diagnostics of acute arthritis commonly does not cause specific difficulities, specially and determination etiologic moments, for example previous acute otitis, parotits, influenza, rheumatic attack, acute trauma ..etc .

1. Concrete aims:

1.A student must familiarize with the problem of realization of diseases of temporomandibular joint for children, among the different age-related groups.

2. A student must know the features of anatomic structure of maxillufacial area for the children of the different age-related groups and feature of physiology processes for children. A student must know classification of diseases of temporomandibular joint.

3. A student must lay hands on methodologies of the diseases of temporomandibular joint for children.

4. A student must conduct differential diagnostics of the different urgent states and render the first medical aid.

3.Educator aims:

1. To develop professional internalss and feelings of responsibility during realization of treatment diseases of temporomandibular joint for children.

2. Able to carry out and psychological approach in-process with children

3 Base knowledges, abilities, habits which are necessary for study the topic.

Names of previous disciplines

Skills are got

  1. General anatomy

The structure of the maxillofacial region, the blood and nerve supply

  1. Gistology

Histological structure of the oral mucous cavity. The mechanism of development and phase of inflammation

  1. Therapy, pediatrics

Know the features of a child's body. Know the basic diseases of importance in conducting the diagnosis of major dental diseases




  1. Task for independent work during preparation to employment.



4.1. List of basic terms, parameters, descriptions which a student must master at preparation to employment :

Term

Determination

1. Impaired functions of the joint

Results from dislocation –intra arthral cause ,or from contracture of various origin-extra arthral cause

2.Dystrophic degenerative process

Disgnated as sclerongenic or deforming arthrosis can be primary or secondry

3.Mount peaks

Causing dramatic impairment of movement of the jaw possiblity resulting incomplete dysfunction


4.2. Theoretical questions to employment:

1. Anatomo-physiologic features of TMJ

2.advantage and disadvantages of contemporary classifications of TMJ disorders

3.clinical signs and methods of treatment of acute and chronic arthritis of TMJ

4.pecular development and types of arthrosis of TMJ

5.main manifestation of dysfunctions of TMJ, views concerning their origin and development

6.main methods of diffrential diagnosis of inflammatory, inflammatory-dystrophic diseases and dysfunction of TMJ

4.3 Practical works (tasks)

To conduct the different types of the local anaesthetizing on phantoms.



5. A plan and organizational structure of lesson in discipline.



Stages of employment

Distribution of time

Types of control

Facilities of studies

1.

Preparatory stage

15 min

practical tasks, situatioonal tasks, verbal cross-examination at standart list of questions.

Text-books, methodical recommendations.

1.11.1

OThe organizational questions.




1.2

Forming of motivation.

1.3

Control of

initial level of preparation.



2.

Basic stage.


55 min

3.

Final stage

20 min

test tasks




3.1.

Control of eventual level of preparation.




3.2.

General estimation of studing activity of student.

3.3

Informing of students about the theme of next employment.


Maintenance of theme
Anatomy

The temporomandibular joint (TMJ), also known as She craniomandibular joint/articulation is peculiar to mammals. It is the articulation between the squamous parto: the temporal bone and the head of the mandibular condyle. The mandibular articulation is labelled as a bilateral diaithroidial or freely movable joint. It is also considered as complex joint, because it involves two separate synovial joints (right and left), in which there is a presence of intracapsular disc Viscus and both the joints have to function in coordination. The TMJ articulation consists of a mandibular or glenoid fossa, an articular eminence or tubercle, condyle, a separating disc, a joint fibrous capsule and an extracapsular check ligaments.

Articulatory System

The articulatory system comprises of the following:

a. Temporomandibular joint (TMJ)

b. Masticatory and accessory muscles.

c. Occlusion of the teeth.

The function is governed by sensory and motor branches of the third division of the trigeminal nerve (mandibular nerve) and a few fibers of the facial nerve. The occlusion of the teeth plays an important role in the function of the TMJ. Normally, the greatest part of the force of mastication is borne by the dentition of the

jaws, but in case of occlusal disharmony, a great deal of force can be shifted to the joint itself.

Mandibular (Glenoid) Fossa (Cranial Component)

Anteriorly, the articular eminence or tubercle, and posteriorly, a small conical postglenoid tubercle.

Articular eminence It is a small prominence on the zygomatic arch. It is strongly convex ant crop osteriorly and somewhat concave medio laterally.

Postglenoid tubercle It separates the articular surface of the fossa laterally from the tympanic plate. And the tympanic plate separates the TMJ from the bony part of the external auditory canal.

Glenoid fossa it has an anterior articular area formed by the inferior aspect of temporal squama. Its surface is smooth, oval and deeply hollowed out and the bone is very thin at the depth of the fossa. This roof of the glenoid fossa creates a partition between middle cranial fossa and tire joint. The fossa is lined by a dense avascular fibroca tillage. In cross section, the fossa and the eminence form S' posteroanteriorly. Squamo-tympanic fissure separates it from tympanic plate, which forms a posterior wall of the glenoid fossa.

Mandibular Component Mandibular Condyle

The articular part of the mandible is an ovoid condylar process (head) with narrow mandibular neck. 11 is broad laterally and narrower medially. The medtolate-ral dimension varies between 13 to 25 mm and anteroposterior width varies between 5.5 to 16 mm. The majority of human condyles {58%) are slightly convex superiorly, with a radius of curvature greater than the distance from the medial to lateral poles. Twenty-five per cent of condyles may be flat superiorly and approximately 12 per cent are pointed or angular in shape and 3 per cent are bulbous or rounded in shape. The surface of the articular eminence that most closely approximates the condyle is consistently congruent with the surface of the condyle. The two condyles of a patient may be asymmetric. A combination of flat condyle on one side with a convex condyle on the other side is most common. The articular part of the condyle is covered by fibrocartilaginous tissue and not with hyaline cartilage, as in most other joints in the human body.

TMJ Capsule

TMJ capsule is a thin sleeve of fibrous tissue investing the joint completely. It is a funnel-shaped capsule, which blends with the periosteum of the mandibular neck and it envelops the meniscus. Tt is attached above anteriorly to the anterior border of the articular eminence and posteriorly to the lip of the squamo-tympanic fissure and to the anterior surface of the postglenoid process and also to the circumference of the cranial articulating surface and bolow to the neck of the condyle, on the lateral as well as on the medial aspect. Tnside this fibrous tissue capsule, there is a lining of silky synovial membrane.
Ligaments

Lateral or Temporomandibular Ligament

TMJ capsule is reinforced by this main stabilising l igament. Tt extends downward and backward from the articular eminence to the external and posterior side of the condylar neck. Its posterior fibers are united with the capsular fibers. This ligament is composed of collagenous fibers that have specific length and poor


ability to stretch, hence it maintains the integrity and limits the movement of TMJ. It mainly Limits the anterior excursion of the jaw as well as prevents posterior dislocation, hence it is called as 'check ligament' of TMJ. But in certain situations, if the joint movements consistently function against ligament, then the ligament elongates and diis can create change in the joint biomechanics and can lead to certain pathologic changes.

Accessory ligaments make no contribution to joint activity.



Sphenomandibular ligament A flat band arising from the sphenoid spine and the petrotympanic fissure, runs downward and medial to the TMJ capsule and gets inserted on the lingula of the mandible. It is a remnant tif Meckel's cartilage. Sphenomandibular ligament is mi important landmark during surgery, as internal maxillary artery and auriculotemporal nerve lies between it and the mandibular neck.

Tlie stylomandibular ligament It is dense, thick band of the deep cervical fascia extending from the styloid process to the mandibular angle.
Articular Disc or Meniscus

The TMJ is a diarthroidial synovial paired joint. This means that there are two joint movements, which occur in separate compartments of this synovial joint and that one joint cannot operate without the other.

The meniscus or an intervening disc divides the articular space into two compartments:


  1. The hivcr or inferior compartment—condyiodiscal complex between tlie condyle and the disc.

  2. Thv upper (temporodiscnl) or superior compartment between the disc and the temporal bone or glenoid fossa.

The disc is biconcave in the sagittal section. The superior surface is ennravoconvex to match the anatomy of the glenoid fossa and inferior surface is concave to fit over the condylar head. A detailed study by Rees in 1954 reported that the shape of the arriadar disc or meniscus is like a school boy's or jockey's cap which overlaps the condylar head .

Temporomandibular Joint (TMJ) Disorders

Classification

i. Intra-articular origin or intrinsic disorders.

ii. Extra-articular origin or extrinsic disorders. Extrinsic factors are those not directly associated with the TMJ, whereas intrinsic factors relate to those conditions existing within the confines of the capsule of the joint-Disorders due to Extrinsic Factors

Masticatory muscle disorders

a. Protective muscle splinting.

b. Masticatory muscle spasm (MPD syndrome).

c. Masticatory muscle inflammation (myositis).



Problems that result from extrinsic trauma

a. Traumatic arthritis

b. Fracture

i. Internal disc derangement

d. Myositis, myospasm

c. Tendonitis

f. Contracture of elevator muscle—myofibrotic contractures.

Because of these ex tra-articular factors the function of the TMJ may be hampered.



Whenever, there is a restriction of normal oral opening or inability to open the mouth fully, the term trismus is used. Trismus is brought about by extraarticular causes and it is also labeled as false ankylosis,Trismus is also defined as a condition in which muscle spasm or contracture prevents opening of the mouth (due to infection or other conditions which alter muscle structure).

Causes of trismus

  1. Due to infection Orofacial infections around the joint area can bring about trismus or limitation of oral opening. Odontogenic acute infections like pericoronitis, Ludwig's angina, submasseteric and infratemporal abscess, etc. Chronic infections affecting the jawrs also can bring about trismus. Tuberculous osteomyelitis of ramus and/or body mandible, etc.

  2. Trauma Fracture of the zygomatic arch may impinge on the coronoid process and restrict the oral opening. Fracture of the mandible also can bring about trismus, because of pain and tenderness or muscle spasm.

  3. Inflammation Myositis or muscular atrophy can bring about trismus.

  4. Myositis ossificans Following trauma, a haema-loma can be formed, within the fibers of the masticatory group of muscles, especially in the masseter, which can progress into ossification and the muscle stiffness. Clinical and radiographic examination will confirm the presence of these changes.

  5. Tetany Typical carpopedal spasm along with trismus can be seen due to hypocalcacmia.

  6. Tetanus Following acute infection by Clostridium tetani, the typical lockjaw symptom can be seen associated with other symptoms, because of persistent tome muscle spasm.

7: Neurological disorders Epilepsy, brain tumour, bulbar paralysis, embolic haemorrhage in medulla oblongata can bring about trismus.

  1. Psychosomatic trismus It is also known as trismus hystericus. Due to extreme fear, anxiety associated with hysterical (its.

  2. Drug induced trismus Strycluvinc poisoning can bring about spasms leading to trismus.

  3. Mechanical blockage Elongation, exostosis, osteoma, osteochondroma of coronoid process will cause mechanical blockage and interfere with the normal mandibular movements.

  4. Extra-articular fibrosis Chronic cervicofacial sepsis, postradialion therapy, ossification of sphenomandibular ligament, bands of scars and burns of the face and neck region, oral submucous fibrosis will lead toward progressive trismus.

classical clinical example of trismus is seen occasionally, following the injection of the inferior alveolar nerve block with local anaesthetic agent. Bleeding, created by needle puncture in the medial pterygoid muscle, produces a haematoma followed by fibrosis and subsequent trismus. In most cases the haematoma is spontaneously resolved and normal jaw function returns within a week or two. In some of the cases, under sedation or general anaesthesia, manipulation of the jaw, with jaw stretcher may be required to break up the adhesions and restore the function.
Disorders due to Intrinsic Factors

1. Trauma

a. Dislocation, subluxation

b. Hacmarihrosis

c. Intracapsular fracture, extracapsular fracture

2. Disc displacement

a. Anterior disc displacement with reduction

b. Anterior disc displacement without reduction

3. Arthritis

a. Osteoarthrosis (degenerative arthritis, osteoarthritis)

b. Rheumatoid arthritis

c. Juvenile rheumatoid arthritis

d. Infectious arthritis

4. Droelopmental defects

a. Condylar agenesis or aplasia unilateral bilateral

b. Bifid condyle

c. Condylar hypoplasia

d. Condylar hyperplasia



  1. Ankylosis

  2. Neoplasms

a. Benign tumours: osteoma, osteochondroma, chondroma

b. Malignant tumours: Chondrosarcoma, fibrosarcoma, synovial sarcoma.



Dislocation, Subluxation, Hypermobility of TM Joint

During normal or unstrained opening of the mouth, the condylar heads translate forward to a position under the apices of the articular eminences. If oral opening proceeds to its maximum capacity, the condylar heads move to the anterior slope of the articular eminences in many normal individuals. F.m ur-.ion of the condylar heads beyond these limits maybe viewed as abnormal and termed as dislocation. In contrast to the fracture dislocation of the condylar head, here the intact condylar head is displaced out of glenoid fossa, much anteriorly beyond articular eminence, but still remains within the capsule of the joint. As far back as 3000 BC in Egypt, Hippocrates first reported a dislocation of the mandible. His method of reduction has survived the ages and is still being used in modern times. Mandibular condylar dislocation is uncommon, compared to the other joints in the body. Its incidence is reported to be 3.1 per cent.



The dislocation can be unilateral or bilateral.

Anterior mandibular dislocation can be classified as

  1. Acute

  2. Chronic recurrent (habitual) subluxation

  3. Long-standing.

The term luxation is also used for acute dislocation and the terms, subluxation or liypermobillty or habitual chronic recurrent dislocation is substituted for the term dislocation, when it is incomplete.
Causes of Acute Dislocation

a. Extrinsic forces or iatrogenic causes

b. Intrinsic or self-induced forces

Anterior acute dislocation of the condyle occurs, in which the normal anatomic relationships within the joint have been completely disrupted,with the condyle lixed anterior to the articular eminence. Relocation of the condyle in its normal position in the glenoid fossa does not occur voluntarily, it can occur as a single acute event or as chronic recurrent episodes.



Extrinsic or iatrogenic causes Acute dislocation is common and can be brought about by a blow on the chin, while mouth is open, injudicious use of mouth gag during general anaesthesia or excessive pressure on the mandible, during dental extraction can lead to acute dislocation. It can be post-traumatic, spontaneous or associated with psychiatric illness.

Predisposing factors Laxity of ligaments, capsule and abnormality of skeletal form. Previous injuries, occlusal disharmonies can bring about laxity of the capsule. Flattened eminence and shallow fossa, systemic diseases like Parkinson's disease, epilepsy, Ehlers-Danlos syndrome, etc. can be the predisposing factors. The use of antipsychotic drugs may cause extrapyramidal reactions and dislocation.

Clinical picture of acute dislocation Dislocation is a dramatic event. It maybe unilateral or bilateral. 1 listory of the patient may be diagnostic.

Unilateral acute dislocation It is characterized by difficulty in mastication and swallowing. Speaking may be difficult and profuse drooling of saliva can be present in the early stages. A deviation of the chin toward contralateral side is seen.The deviation produces a lateral cross and open bite on the contralateral side .

Tlie mouth is partly open and the affected condyle cannot be palpable. In obese person, absence of condyle from the glenoid fossa may not be apparent, but in others a definite depression will be seen and felt in front of the tragus.



Bilateral acute dislocation It is associated with pain, inability to close the month, tense masticatory muscles, difficulty in speech, excessive salivation, protruding chin I he mandible is postmed forward and movements are restricted. There is a gagging of the molaT teeth with the presence of anterior open bite. Difficulty in swallowing and drooling of saliva is seen. Patient will complain of pain in the temporal region rather than the joint and may be extremely apprehensive. The distinct hollow-ncss can be felt in both the preauricular regions, Associated muscle spasm contributes to the fixed position of the condyles.

Literature.

Basic:

1.Lectures which are read on the department of pediatric dentistry.

2. Pinkham J.R. Pediatric dentistry. – 2nded.- W.B. Sounders Company. – 1994.- 647 p.

3. Pediatric dentistry /Ed. R.R.Welbury.- Oxford, 1997 – 584p.



Additional:

  1. Колесов А.А “ Стоматологія дитячого віку “ , 1978 ,ст. 44-63.

  2. Дунаевський В.А. “Хірургічна стоматологія “ , 1979 ,ст. 111-118.

  3. Бернадский Ю.И. «Основы хирургической стоматологии», К., 1998

  4. Евдокимова А.И. «Руководство по стом. детского возраста», 1976






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