Pathology and Medical Management TMJ Disorders and Diseases.
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Transcript of Pathology and Medical Management TMJ Disorders and Diseases.
Pathology and Medical Management TMJ Disorders and Diseases
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Symbols this is for your
information only, it won’t be used for the
exam
important to know for exam
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Temporomandibular Joint ImagingRadiography:
◦ Fractures which might occur.
◦ Can also get an idea of the joint position
Generally not as useful as other types of imaging studies
Standard Views:◦ Transcranial View◦ Submentovertex
view◦ Cephalometry:
lateral views
MRI: T1-weighted sagittal images are the method of choice for TMJ examination.◦ Articular disk position
T2 weighted images◦ Periarticular changes◦ Joint effusions
CT
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Figure 5. a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position.
Sommer O J et al. Radiographics 2003;23:e14-e14
©2003 by Radiological Society of North America
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TMJ Dysfunctions
Non-Inflammatory Inflammatory MPDS
Articular Non Articular
Articular Disk Displacement
With Reduction
Deviation in Form
Dislocation and Subluxation
Fibrosis
Without Reduction
Ankylosis
Bony
Synovitis and Capsulitis
Arthritic Disorders
Osteoarthritis
Rheumatoid Arthritis
Other
Myositis
Spasm
Muscle Contracture
www.geocities.com/dentalsem/Temporomandibular...
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Articular Disk Displacements with ReductionPartial Anteromedial Disk
Displacement◦Disk slides anterior on the condyle◦Posterior band is more anteriorly
placed than normal◦Etiology:
Thinning of the posterior band Minimal elongation of diskal ligaments
◦TX: intro-oral appliances in combination with stress reduction
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Disk DisplacementAnteromedial Disk Displacement with
Reduction◦ Definition: Change in the disk-condyle
structural relation during mandibular translation with mouth opening and closing
◦ Etiology: Articular surface irregularity Disk-articular surface adherence Synovial fluid degradation Myofascial imbalances around the joint Increased elongation of diskal ligaments and
posterior attachment
www.urmc.rochester.edu/smd/Rad/tmj.htm
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5 Progressive StagesStage I Disk Displacement
◦Temporal mandibular ligament becomes elongated
◦Disk drops medially - subluxes which reduces upon closure
◦Ligament brings the disk back into place upon closure
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Symptoms of Stage 1:Very little pain
Inconsistent click occurs early in opening phase.
Subluxation on opening and a lateral reduction in closing
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Stage II Disk DisplacementTM ligament continues to
elongate, disk moves more medial and anterior on mandibular head.
Reduction on mouth opening,
subluxation on closingClicking: Early on opening and
Late on closing
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Figure 11. Partial anterior disk displacement.
Sommer O J et al. Radiographics 2003;23:e14-e14
©2003 by Radiological Society of North America
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Symptoms of 2:◦ Reciprocal click early
on opening and late on closing
◦ Pain
Signs: C curve upon mouth opening: goes back and lateral towards dysfunctional side.
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Open Lock: Potential to occur from Stage II
on
Signs: two opening clicks Two closing clicks Condyle can be prevented from slipping
back in place if disk lies too posterior to the condyle
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Stage IIISignificant TM ligament
elongation overstretching occurs causing posterior ligament elongation, disk shape distorted.
Condyle loses vertical height Capsule becomes shortened
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Symptoms 3: click is more consistentClick occurs later on opening and earlier on closing◦ Most painful stage
Signs: ◦ C curve ◦ Limited range of mouth opening to 25 to
30 mm, just below functional: 35mm is limit.
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Closed Lock conditionClosed lock: sudden limitation of
jaw opening◦Disk is permanently lodged
anteriorly and interferes with normal rotation and translation of the joint
◦Hard end-feel
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Stage IV: Rotational DisplacementSymptoms: Pain
Signs:◦Clicking rare or single opening click
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Stage V:Signs: radiographic degenerative
changes on condylar head, articular eminences (less often)
Evidence of remodeling (sclerosis) and osteophytes
Marked deformity of disk, thickening of disk and shape change
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C. Anteromedial Disk Displacement with Intermittent LockingDisk is displacedShape is deformed over time
from biconcave to biconvex
Symptoms: intermittent locking in the am or after a period of clenching or chewing on involved side, brucsizum (teeth clenching @ night)
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D. Anteromedial Disk Displacement without ReductionDefinition: change of the disk-condyle
structural relationship which is maintained during mandibular translation◦ Disk remains displaced with a closed-lock
occurring◦ Lose: contact with condyle, disk and articular
eminence of condyle which prevents posterior translation from occurring
Signs: ◦ Deviation of mandible towards involved side◦ Marked limitation of lateral deviation to
contralateral side
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Internal Derangement of the Disk Deviation in Form
◦Frictional Disk Incoordination: Definition: intra-articular disk adheres to
the eminence Onset: Etiology: loss of lubrication, roughness in
the articular surface Signs: loss of translatory glide
opening click Symptoms: minimal discomfort with the
click
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Deviation in FormArticular Surface Defects
◦ Definition: articulating surface has a roughed area or a change in the articular cartilage which doesn’t allow smooth rolling or gliding during opening and closing of the mouth
◦ Etiology: ◦ Signs: reciprocal click during opening and
closing of the mouth Lateral deviation on opening
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Deviation in FormDisk Thinning and perforation
◦Etiology: application of excessive pressure on the TMJ, overloading with teeth together
◦Symptoms: variable joint tenderness, muscle pain
◦Signs: grating sound, crepitus during opening and closing
◦DX: made with medical imaging studies
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Hypermobility and Dislocation
-Hyper: at risk for a locked open mouth.
Subluxation
Dislocation
Hypomobility: capsular vs adhesive disk
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A. Joint SubluxationMandibular Head Subluxation
1. Biomechanical considerations
2. Arthrokinematic dysfunctions
a. max. rotation occurs before translation begins
b. maximum translation occurs and a shift of condyle and disk as a unit occurs
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Subluxation versus Reduction of Displaced DiskSubluxed Disk:
◦Occurs only on wide opening◦Does not occur with protrusion or
lateral deviation◦Pain is not always present
Reduction Disk:◦Occurs on opening for stage I,
closing (except in stage 1) and protrusion and contra-lateral lateral deviation
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B. Joint DislocationCondyle moves outside of the physiological
boundaries of the joint
Etiology: yawning (to wide), singing, sleeping with head on forearm, excessive tooth abrasion, malocclusion, over-closure and trauma
Sx: open lock position mouth is unable to close, locked open
Rx: manipulation, splint
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Ankylosis: stuck
Fusion of TM joint◦ Fibrosis
◦ Bony
Symptoms: ◦ Opposite side may
become painful
Signs: ◦ Decreased ROM◦ C curve on mouth
openingTx
◦ How to f(x) with it.
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Adhesive Disk HypomobilityDefinition: intra-articular
formation of adhesions within the disk◦Usually in the superior joint cavity,
causes loss of condylar translation
◦Condylar displacement of disk may occur
◦Distortion of disk on mouth opening
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Adhesive HypomobileEtiology:
◦Trauma: mild may only cause frictional disk incoordination or articular surface defect
◦Major: intra-articular bleeding, swelling, fibrosis can result Restricts ROM May progress to joint degeneration
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Sx: Click – ◦ Early is within 10 mm of opening, ◦ Intermediate between 10 and 20 mm, ◦ Late after 30 mm of opening. ◦ C/o a locking sensation
Signs: ◦ mandible deviates away from the
dysfunctional side during mouth opening ◦ S-curve: jaw goes to both sides
correcting and over-correcting.
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Inflammatory ConditionsSynovitis and Capsulitis
◦RetrodiscitisArthritic Conditions
◦Osteoarthritis◦Rheumatoid Arthritis◦Other Arthritic Conditions
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Capsulitis
◦ SX: continuous deep constant pain Originates in joint area Pain with mouth opening
◦ Signs: palpable pain with compression to the lateral pole of condyle Limitation of mouth opening Myospasms secondary to pain Tissue stretch end feel or empty end feel Decreased protrusion , may deviate to side of
dysfunction Increase pain with passive stretch
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Retrodiscitis
Anterior displacement of disk, condyle presses on posterior tissue causing an inflammatory reaction
Hx: trauma, chronic bruxing
SX: constant, dull, aching pain, aggravated by joint movement
-closure puts it back into place.
Signs: empty end feel, acute malocclusion, decrease protrusion, pain with compression
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Non-Articular ConditionsMuscle Spasms
◦Masseter◦Temporalis◦Lateral Pterygoid◦Medial Pterygoid
MyositisMyofascial Pain Syndrome Muscle Contracture
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Practice Pattern 4E:Muscle Spasms
◦Causes: trauma, occlusal imbalance, changes in vertical dimensions between teeth, immobilization, prolonged dental procedures, chronic teeth clenching, disease
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Three Categories of Muscle Spasms1. Protective Co-contraction: muscle guarding
◦ Causes: Chronic inflammatory process, emotional stress, habit, muscle tendon injury
Sx: pain with active jaw movement
Signs: pain with resisted movements, pain at end range with passive movements, empty end feel or muscle spasm end feel
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2. Local Muscle SpasmProtective muscle co-contraction,
◦ Leads to prolonged isometric contraction of muscle.
◦ Leads to decrease in blood flow, ◦ Inflammatory response, increase pain, increase
muscle guarding, more pain
History: blow to face, dislocation of jaw
SX: periarticular, pain with chewing
Signs: pain with AROM mouth opening, PROM, Resisted muscle testing, dec. in mouth opening pain with overpressure during mouth opening
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3. Specific Muscles, Trigger Points1. Temporalis
a. HX: headaches in temporal region
b. SX: headaches, visual disturbances,
pressure behind eye, increase eye fatigue, difficulty with night
vision
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c. Signs:
◦Muscle trigger point with referred pain pattern
◦S curve on mouth opening ◦Decrease in freeway space
(mouth opening at rest) ◦Abnormal protrusion of
condyle on contralateral side during lateral deviation
◦ Intermittent tooth ache
Restriction of mouth opening
Deviation of mouth toward affected side
Pain with palpationPain with resisted
motions of elevation but not protrusion
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2. Masseter
a. HX:
b. SX: pain to lower jaw, molar
teeth and related gums,
pain with chewing or with increased jaw activity
unilateral tinnitus
Bruxism: jaw clenching
c. Signs: ◦ restriction of mouth opening
◦ deviation of mouth toward affected side
◦ pain with palpation
◦ referred pain pattern upon compression
◦ pain with resisted motions of elevation but not protrusion
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3. Medial Pterygoid
Ache inside the mouth
a. HX:
b. SX: ◦ Pain with wide
mouth opening◦ pain with clenching
teeth◦ painful swallowing
c. Signs:◦ Restriction in mandibular
opening
◦ No deviation of jaw
◦ Rarely the primary muscle, Usually a 2ndary area
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4. Lateral Pterygoid:
“TMJ” dysfunction
a. SX: ◦Pain in region
of TMJ and maxilla
◦Clicking sounds may occur, so need to be careful to d(x)
b. Signs: ◦ Pain with compression on
same side as dysfunction
◦ Slight restriction of mouth opening, occlusal abnormality
◦ ROM: for Lateral deviation away from the side of dysfunction is decreased
◦ ROM decreased
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OncologicalA. Rare occurrences, but can get a
metastatic adenocarcinoma in the TMJ region
B. Signs: unrelenting pain of unexplained origin, neurological deficits, nausea, balance disorders, visual changes, cranial nerve disorders
C. Refer if suspect
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PT TREATMENT OF TMJ DYSFUNCTIONSGoals are based on physical exam1. Treat pain: 2. Address biomechanical
asymmetries 3. Postural education: like forward
head4. Strengthen supporting
structures necessary to balance head, maintain new position
5. Stress reduction
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Occlusional appliance:Splint: removable,
hard, acrylic “bite guard” a. muscle relaxation b. anterior (orthopedic) repositioning
appliance c. anterior bite plate d. posterior bite plate
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Medical Treatment:Arthroscopic surgery done for
disk repositioning
Decrease adhesions
Take out osteophytes
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Other References:1. Bourbon BM: “Craniomandibular
Examination and Treatment” in Saunders Manual of Physical Therapy Practice, WB Saunders Co. Philadelphia, 1995
2. Richardson JK and Iglarsh ZA. Clinical Orthopaedic Physical Therapy, W.B. Saunders Co., Philadelphia, 1994.
3. Magee D. Orthopedic Physical Assessment, 4th ed. 2002