A. Anatomy Review (The Stomatognathic System)

Disorders of the TMJ

A. Anatomy review (the stomatognathic system):

1. teeth: occlusal stop, functional articulating surfaces, PDL

2. joints

a. bones

b. meniscus

c capsule plus ligament

d. blood vessels

e. nerves

f. histology: bones, articular fibrocartilage, bilaminar zone

3. muscles

a. closers: masseters, medical pterygoids

b. positioners: temporalis

c. openers: suprahyoids

d. lateral pterygoid: inferior and superior belly

B. Physiology Review:

1. very powerful and very active muscle system

2. fixed end point of jaw motion

3. rotation / translation through both joint spaces

4. both joint act in concert

5. role of the articular fibrocartilage

6. (functional range) CR vs. CO?

7. role of proprioception

References: Rees, L.A. The structure and function of the mandibilar joint. J Br Dent Ass, 1954, 96(6):125

Keith, D.A. Development of the human TMJ. Br J Oral Surg, 1982, 20:217

De Bont, et al. Osteoarthritis and internal derangements of the TMJ:a light microscope study. JOMS, 1986, 44(8):634

CLASSIFICATION OF DISORDERS

C. Disorders: Despite the emphasis on the distinction between MPD and ID, it must be borne in mind that these often occur together and that there is a vast array of other disorders may affect the TMJ and associated structures. This entire spectrum must be considered when evaluating a patient with TMJ complaints.

1. Muscle Dysfunction (MPD):

- Signs and symptoms

- Epidemiology

- Etiology

2. TMJ Internal Derangements:

- Definition

- Biomechanics

- Signs and symptoms

3. Combination of ID and MPD:

- Cause and effect?

Reference: Eversole, I.R. and J. Machado., TMJ internal derangements and associated neuromuscular disorders. JADA, 1985, 110:69.

D. DIAGNOSIS , CLINICAL AND IMAGING: As in many clinical situations the key to effective diagnosis is thorough history taking and examination. In the case of the TMJ it may be said that imaging procedures are used essentially for confirmation of clinical findings.

1. History:

1. time of onset of symptoms

2. possible etiology

3. progression

4. location

5. sounds

6. other treatment and its effect

7. what makes things better or worse

8. habits

2. Examination:

1. appearance

2. range of motion

3. muscle palpation

4. occlusal examination

3. Imaging:

1. plane films

2. panorex

3. tomograms

4. arthrograms

5. arthrotomograms

6. double space, air contrast arthrotomograms

7. CT

8. MRI

9. nuclear scans

References: Westesson. Double contrast arthro-tomography of the TMJ. Introduction of an arthographic technique for visualization of the disc and articular surfaces. JOMS, 1983, 41(3):163.

Wilk, et. al., Magnetic resonance imaging of the temporomandibular joint using a surface coil. JOMS, 1986, 44(12):935.

E. NONSURGICAL MANAGEMENT: All management, be it surgical or nonsurgical, of course depends on the diagnosis. The two main problems are MPDS and ID of the joint. Non surgical management of these includes:

1. MPDS:

1. live with it

2. education

3. home physio

4. outpatient physio

5. splints

6. pharmacology

2. TMJ ID

1. live with it

2. splint

3. outpatient physio

4. ortho

5. prosthesis

6. pharmacology

F. SURGICAL MANAGEMENT: Surgical exploration of TMJ has in itself prompted an improved understanding of the pathology of internal derangement and prompted the evolution of many of the diagnostic modalities used today.

1. Surgery for Internal Derangements of the TMJ:

1. Who is a candidate for TMJ surgery?

2. Surgical anatomy: preauricular approach to the TMJ

3. Eminectomy

4. Menisectomy

5. Condylotomy

6. Condylectomy

7. Meniscal repositioning

8. Arthroscopy

2. Miscellaneous:

1. TMJ reconstruction

2. Surgery for dislocation

3. Trauma

4. Future perspective