TMJ ANKYLOSIS: ETIOLOGY, PATHOGENESIS, CLINICAL MANIFESTATIONS, DIAGNOSIS AND TREATMENT.
CONTRACTURE OF THE MANDIBLE: ETIOLOGY, CLASSIFICATION, CLINICAL FEATURES, DIFFERENTIAL DIAGNOSIS, TREATMENT, PREVENTION.
DISLOCATIONS OF MANDIBLE: ETIOLOGY, CLASSIFICATION, CLINICAL FEATURES, DIFFERENTIAL DIAGNOSIS, TREATMENT, PREVENTION.
TMJ
The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. There are two TMJs, one on each side, working in unison. The name is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jaw bone called the mandible. The unique feature of the TMJs is the articular disc. The disc is composed of fibrocartilagenous tissue (like the firm and flexible elastic cartilage of the ear) which is positioned between the two bones that form the joint. The TMJs are one of the few synovial joints in the human body with an articular disc, another being the sternoclavicular joint. The disc divides each joint into two. The lower joint compartment formed by the mandible and the articular disc is involved in rotational movement—this is the initial movement of the jaw when the mouth opens. The upper joint compartment formed by the articular disk and the temporal bone is involved in translational movement—this is the secondary gliding motion of the jaw as it is opened widely. The part of the mandible which mates to the under-surface of the disc is the condyle and the part of the temporal bone which mates to the upper surface of the disk is the glenoid (or mandibular) fossa.
Pain or dysfunction of the temporomandibular joint is commonly referred to as “TMJ”, when in fact, TMJ is really the name of the joint, and Temporomandibular joint disorder (or dysfunction) is abbreviated TMD. This term is used to refer to a group of problems involving the TMJs and the muscles, tendons, ligaments, blood vessels, and other tissues associated with them. Some practitioners might include the neck, the back and even the whole body in describing problems with the TMJs.
Temporomandibular joint disorder, TMJD (in the medical literature TMD), or TMJ syndrome, is an umbrella term covering acute or chronic pain, especially in the muscles of mastication and/or inflammation or the temporomandibular joint, which connects the mandible to the skull. The primary cause is muscular hyper- or parafunction, as in the case of bruxism, with secondary effects on the oral musculoskeletal system, like various types of displacement of the disc in the temporomandibular joint. The disorder and resultant dysfunction can result in significant pain, which is the most common TMD symptom, combined with impairment of function. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry and neurology — there are a variety of treatment approaches.
The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, neoplasia, and reactive lesions.
Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex, but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.
Symptoms associated with TMJ disorders may be:
■ Biting or chewing difficulty or discomfort
■ Clicking, popping, or grating sound when opening or closing the mouth
■ Dull, aching pain in the face
■ Earache (particularly in the morning)
■ Headache (particularly in the morning)
■ Hearing loss
■ Migraine (particularly in the morning)
■ Jaw pain or tenderness of the jaw
■ Reduced ability to open or close the mouth
■ Neck and shoulder pain
■ Dizziness
TMJ disorders
Temporomandibular joint and muscle disorders (TMJ disorders) are problems or symptoms of the chewing muscles and joints that connect your lower jaw to your skull.
See also: Facial pain
Alternative Names
TMD; Temporomandibular joint disorders; Temporomandibular muscle disorders
Causes, incidence, and risk factors
There are two matching temporomandibular joints — one on each side of your head, located just in front of your ears. The abbreviation “TMJ” literally refers to the joint but is often used to mean any disorders or symptoms of this region.
Many TMJ-related symptoms are caused by the effects of physical stress on the structures around the joint. These structures include:
- Cartilage disk at the joint
- Muscles of the jaw, face, and neck
- Nearby ligaments, blood vessels, and nerves
- Teeth
For many people with temporomandibular joint disorders, the cause is unknown. Some causes given for this condition are not well proven. These included:
- A bad bite or orthodontic braces
- Stress and tooth grinding. Many people with TMJ problems do not grind their teeth, and many who have been grinding their teeth for a long time do not have problems with their TMJ joint. For some people, the stress associated with this disorder may be caused by the pain as opposed to being the cause of the problem.
Poor posture can also be an important factor in TMJ symptoms. For example, holding the head forward while looking at a computer all day strains the muscles of the face and neck.
Other factors that might make TMJ symptoms worse are stress, poor diet, and lack of sleep.
Many people end up having “trigger points” — contracted muscles in your jaw, head, and neck. Trigger points can refer pain to other areas, causing a headache, earache, or toothache.
Other possible causes of TMJ-related symptoms include arthritis, fractures, dislocations, and structural problems present since birth.
Symptoms
Symptoms associated with TMJ disorders may be:
- Biting or chewing difficulty or discomfort
- Clicking, popping, or grating sound when opening or closing the mouth
- Dull, aching pain in the face
- Earache
- Headache
- Jaw pain or tenderness of the jaw
- Reduced ability to open or close the mouth
Signs and tests
You may need to see more than one medical specialist for your TMJ pain and symptoms, such as your primary care provider, a dentist, or an ear, nose, and throat (ENT) doctor, depending on your symptoms.
A thorough examination may involve:
- A dental examination to show if you have poor bite alignment
- Feeling the joint and connecting muscles for tenderness
- Pressing around the head for areas that are sensitive or painful
- Sliding the teeth from side to side
- Watching, feeling, and listening to the jaw open and shut
- X-rays to show abnormalities
Sometimes, the results of the physical exam may appear normal.
Your doctor will also need to consider other conditions, such as infections, ear infections, neuralgias, or nerve-related problems and headaches, as the cause of your symptoms.
Treatment
Simple, gentle therapies are usually recommended first.
- Learn how to gently stretch, relax, or massage the muscles around your jaw. Your doctor, dentist, or physical therapist can help you with these.
- Avoid actions that cause your symptoms, such as yawning, singing, and chewing gum.
- Try moist heat or cold packs on your face.
- Learn stress-reducing techniques.
- Exercising several times each week may help you increase your ability to handle pain.
Read as much as you can, as opinion varies widely on how to treat TMJ disorders. Get the opinions of several doctors. The good news is that most people eventually find something that helps.
Ask you doctor or dentist about medications you can use:
- Short-term use of acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), or other nonsteroidal anti-inflammatory drugs
- Muscle relaxant medicines or antidepressants
- Rarely, corticosteroid shots in the TMJ to treat inflammation
Mouth or bite guards, also called splints or appliances, have been used since the 1930s to treat teeth grinding, clenching, and TMJ disorders.
- While many people have found them to be useful, the benefits vary widely. The guard may lose its effectiveness over time, or when you stop wearing it. Other people may feel worse pain when they wear one.
- There are different types of splints. Some fit over the top teeth, while others fit over the bottom teeth.
- Permanent use of these items is not recommended. You should also stop if they cause any changes in your bite.
Failure of more conservative treatments doe not automatically mean you need more aggressive treatment. Be cautious about any nonreversible treatment method, such as orthodontics or surgery, that permanently changes your bite.
Reconstructive surgery of the jaw, or joint replacement, is rarely required. In fact, studies have shown that the results are often worse than before surgery.
Ankylosis (Temporomandibular Joint)
Fig. 5. TMJ – 3D-CT computer image analysis. In this picture is presented TMJ ankylosis.
Ankylosis means fusion of a joint – the fusing together of the bones forming the joint or by the formation of calcium deposits around the ligaments – and can occur either unilaterally or bilaterally, depending on the cause. In the temporomandibular joint (TMJ), ankylosis is most frequently caused by poorly-healing severe trauma or infection. However, it can also occur congenitally, or secondary to severe rheumatoid arthritis or to tumors in the area of the TMJ. In congenital cases, or in children in whom the jaw is still growing, ankylosis can arrest the growth of the lower jaw and cause the face to become asymmetrical.
Symptoms
The chief symptom is a decrease in TMJ range of motion. This results in an inability to chew properly and can make oral hygiene very difficult. In very severe cases it can even cause problems with speech. Ankylosis does not usually cause pain, though pain may be experienced depending on the cause of the condition.
Diagnosis
A dentist or oral surgeon will diagnose the severity of ankylosis by observing the degree to which mouth opening is inhibited. X-rays or other imaging tests such as CT scans or MRI can determine abnormalities in the bony or soft tissue formations in the joint.
Treatment
Jaw exercises may temporarily help to decrease the immobility of the joint in some ankylosis cases, but in most cases treatment of ankylosis will require surgery.
Treatment of ankylosis of the jaw joint involves open surgery to remove the condyle, the rounded end of the lower jaw bone that forms the TMJ. The removed condyle is then replaced with a prosthetic condyle. After the surgery, extensive physical therapy usually plays a crucial role in restoring proper TMJ function.
At the maximum mouth opening, the distance between incisal edges of the middle incisor teeth should be about 3.5 to 4 cm. This distance varies individually, although if a patient cannot open his/her mouth to the distance of at least 3 cm, it can be felt as an unpleasant functional restriction. A restricted ability of the lower jaw to move is designated ascontracture which has several forms:
Inflammatory contracture has its origin at an inflammation around the mandibular elevators (mainly the m. pterygoideus medialis).
Muscular contracture appears by damage of the above mentioned muscle during mandibular anesthesia.
Arthrogenous contracture is caused by inflammations of the mandibular joint or by a chronic traumatization of the joint at occlusion defects.
Fibrous contracture is determined by fibrous changes at the mandibular joint area after traumas or burns.
Neurogenic contracture (trismus) appears at tetanus.
Therapy of restricted mouth opening should focus on elimination of underlying causes. In cases of an inflammation at the mandibular joint area, a temporary loose immobilization of jaws by a wire bonding has its place, besides the anti-inflammatory therapy. At other kinds of contractures, physical therapy (red Solux lamp), active and passive exercises and laser therapy are often used. Fibrous contractures need to be released surgically in some cases.
A total immobility of the mandibular joint is called ankylosis. It is a coalescence of the lower jaw articular process with the temporal bone. Its cause is usually the mandibular joint purulent inflammation associated with otitis or osteomyelitis during childhood, or an intra-articular fracture or contusion with the joint hematoma. It results at a significant restriction of mobility of the mandible. A diagnosis is confirmed by an X-ray examination at Schüller’s projection, or a computer tomography examination. Ankylosis is treated surgically – arthro-plastic surgery – that includes cutting out the bone bridge followed by insertion of other material (fascia, cartilage) into the neo-formed glenoid.
Mandible dislocation is the displacement of the mandibular condyle from the articular groove in the temporal bone. Different types of dislocations can result from traumatic and nontraumatic processes. Most dislocations are managed and reduced in the emergency department with elective follow-up. However, some situations require immediate consultation with an oromaxillofacial surgeon. This article focuses primarily on the diagnosis and management of mandible dislocations in adults.
Anterior dislocation
Posterior dislocation
Superior dislocation
Lateral dislocation
Anatomy
The temporomandibular joint (TMJ) (see the image below) is the articular surface between the mandibular condyles and the temporal bone. Synovial membranes line the space between the two bones. The joint acts with a hinge as well as a gliding mechanism.
The temporomandibular ligament, sphenomandibular ligament, and capsular ligament support the joint. Blood supply is from the superficial temporal branch of the external carotid artery. Branches from the auriculotemporal and masseteric divisions of the mandibular nerve innervate the joint.
Closing of the mandible is performed by the masseter, temporalis, and medial pterygoid muscle. The jaw opens at the temporomandibular joint by traction on the mandibular neck by the lateral pterygoid muscle.
Pathophysiology
The mandible can dislocate in the anterior, posterior, lateral, or superior position. Description of the dislocation is based on the location of the condyle in comparison to the temporal articular groove.
Anterior dislocations are the most common and result in displacement of the condyle anterior to the articular eminence of the temporal bone. These dislocations are classified as acute, chronic recurrent, or chronic.
· Acute dislocations can be seen after trauma or dystonic reactions, but they are usually a result of extreme mouth opening such as with yawning, general anesthesia, dental extraction, vomiting, or seizures. Anterior dislocations after endoscopic procedures have also been reported.
· Anterior dislocations are usually secondary to an interruption in the normal sequence of muscle action when the mouth closes from extreme opening. The masseter and temporalis muscles elevate the mandible before the lateral pterygoid muscle relaxes resulting in the mandibular condyle being pulled anterior to the bony eminence and out of the temporal fossa. Spasm of the masseter, temporalis, and pterygoid muscles causes trismus and keeps the condyle from returning into the temporal fossa. These dislocations can be both unilateral and bilateral.
· Acute chronic dislocations result from a similar mechanism in patients with risk factors such as congenitally shallow mandibular fossa, loss of joint capsule from previous mandible dislocations, or hypermobility syndromes.
· Chronic dislocations result from untreated TMJ dislocations and the condyle remains displaced for an extended time period. Open reduction is often required.
Posterior dislocations typically occur secondary to a direct blow to the chin. The mandibular condyle is pushed posteriorly toward the mastoid. Injury to the external auditory canal from the condylar head may occur from this type of injury.
Superior dislocations, also referred to as central dislocations, can occur from a direct blow to a partially opened mouth. The angle of the mandible in this position predisposes upward migration of the condylar head. This can result in fracture of the glenoid fossa with mandibular condyle dislocation into the middle skull base. Further injuries from this type of dislocation can range from facial nerve injury, to intracranial hematomas, cerebral contusion, leakage of cerebrospinal fluid, and damage to the eighth cranial nerve resulting in deafness.
Lateral dislocations are usually associated with mandible fractures. The condylar head migrates laterally and superiorly and can often be palpated in the temporal space.
Epidemiology
Frequency
Mandibular dislocations are infrequent presentations to the emergency department. Lowery et al reported seeing 37 dislocations over a 7-year period in an emergency setting with approximately 100,000 annual visits. Anterior mandible dislocations are most common and often result from nontraumatic causes.
Mortality/Morbidity
Significant morbidity associated with isolated mandible dislocations is rare. However, fractures of the mandible, maxillofacial, or orbital bones are often seen with traumatic TMJ dislocations.
Mandibular dislocations may be associated with chronic recurrent dislocations, ischemic necrosis of the condylar head, traumatic damage to the articular disk, and mandibular osteomyelitis. Chronic untreated dislocations can result in permanent malocclusion.
Mortality in cases of mandibular dislocation is usually a result of concurrent serious traumatic injuries and not from the dislocation itself.
Treatment
Most temporomandibular disorders (TMDs) are self-limiting and do not get worse. Simple treatment, involving self-care practices, rehabilitation aimed at eliminating muscle spasms, and restoring correct coordination, is all that is required. Nonsteroidal anti inflammatory analgesics (NSAIDs) should be used on a short-term, regular basis and not on an as needed basis. On the other hand, treatment of chronic TMD can be difficult and the condition is best managed by a team approach; the team consists of a primary care physician, a dentist, a physiotherapist, a psychologist, a pharmacologist, and in small number of cases, a surgeon. The different modalities include patient education and self-care practices, medication, physical therapy, splints, psychological counseling, relaxation techniques, biofeedback, hypnotherapy, acupuncture, andarthrocentesis.
As with most dislocated joints, a dislocated jaw can usually be successfully positioned into its normal position by a trained medical professional. Attempts to readjust the jaw without the assistance of a medical professional could result in worsening of the injury. The health care provider may be able to set it back into the correct position by manipulating the area back into its proper position. Numbing medications such as general anesthetics, muscle relaxants, or in some cases sedation, may be needed to relax the strong jaw muscle. In more severe cases, surgery may be needed to reposition the jaw, particularly if repeated jaw dislocations have occurred.
Temporomandibular joint ankylosis (TMA) is a highly distressing condition in which the temporomandibular joint (TMJ) is replaced by scar tissue. The TMA can be classified using a combination of location (intra-articular or extra-articular); type of tissue involved (bone, fibrous, or fibro-osseous); and extent of fusion (complete or incomplete). TMA partially or totally prevents the patient from opening his or her mouth. This disabling condition causes speech impairment, difficulty with mastication, poor oral hygiene, and abnormalities of facial growth, generating significant psychological stress. TMA is most frequently associated with trauma, but local or systemic infection, tumors, degenerative diseases, intra-articular injection of corticoid, forceps delivery, and complication of previous TMJ surgery have also been implicated.
A number of surgical approaches have been devised to restore normal joint functioning and prevent reankylosis. Three basic techniques are used: (a) gap arthroplasty, where a resection of bone between the articular cavity and mandibular ramus is created without any interposition material; (b) interpositional arthroplasty, which adds interpositional material between the new sculptured glenoid fossa and condyle; and (c) joint reconstruction, when the TMJ is reconstructed with an autogenous bone graft or total joint prosthesis.
Surgical intervention for correcting TMA may include autogenous costochondral rib grafts after condylectomy, mainly used for children due to the potential to continuous growth. Gap arthroplasty with tissue interposition between the mandibular ramus and glenoid fossa has been performed mainly in adults. Appropriate interposition materials include: (I) autogenous tissues: meniscus, muscle, fascia, skin, cartilage, fat or a combination of these tissues; (II) allogeneic tissues: cartilage and dura; (III) alloplastic: sialastic materials like acrylic, proplast, and silicone; (IV) xenograft tissues: usually of bovine origin (collagen and cartilage). Gap arthroplasty without material interposition has also been performed. When preserved, the remaining TMJ disc, which has been displaced medially and anteroinferiorly, can be replaced and used as interpositional tissue for preventing reankylosis, in combination with the gap arthroplasty technique. In an alternative intervention described by Salins, no bone is removed from the ankylotic bony mass. The approach proposed by Salins to treat TMA is to convert it into a subcondylar fracture and create a pseudoarthrosis, using the temporal muscle flap and a block of autogenous cartilage or silastic as interpositional material. Partial or total prosthesis for TMJ reconstruction has been used with a variable success rate.
In this report, we present a modification of the conventional vascularized temporal muscle flap, and describe an alternative procedure using a muscle/fascia temporal graft as interpositional tissue for the gap arthroplasty.
Case Description
A 23-year-old female patient sought treatment due to TMA. The patient had a history of mandibular trauma at her left TMJ, addressed by a surgical procedure at the site. Complaints had persisted for three years following a fracture. Pre-operatively, the maximum mouth opening was limited to 15 mm. Facial asymmetry characterized the left side of the face. The 3D computed tomography analysis showed a gross bone mass at the TMJ; coronal CT slices showed that the bony mass extended to the medial cranial base (Fig. 1). Thus, we were able to classify the lesion as true osseous/condyle ankylosis.
Fig.
slice of the left temporomandibular joint ankylosis.
In some cases, nasofibroscopy or tracheotomy requires general anesthesia; however, for this particular case, those procedures were not needed. A vaseline gauze was placed gently in the external auditory meatus and a preauricular incision was made as described by Al-Kayat & Bramley. An avascular tissue plane along the cartilaginous meatus was established using surgical scissors followed by blunt subcutaneous tissue dissection until reaching the superficial temporal fascia (STF). The STF fascia was then incised and retracted anteriorly to protect the facial nerve branches. The periosteum over the zygomatic was then incised and retracted with the STF, revealing the TMJ which was found fused to the temporal bone (Fig. 2A). The excess of bone was removed with a large round bur and chisel, beginning from the condylar neck at the level of the mandibular notch; the glenoid fossa was sculpted at the same level as the original fossa. The gap between condyle and glenoid fossa was then created, taking care to maintain at least 5 millimeters of distance between the skull base and all faces of the condyle. The mandible was then mobilized and the new sculptured condyle was checked verify complete release. At this point, an ipsilateral coronoidectomy was performed via intraoral approach.
Fig. 2. (A) Intraoperative view of the temporomandibular joint ankylosis. (B) Deep temporal fascia and muscle sutured over the reshaped glenoid fossa. Observe the adequate bone removal and the gap between the skull base and the mandible.
A thin layer of temporal deep fascia and muscle was harvested from an area posterior and superior to the ear in order to avoid any branches of the facial nerve, taking care not to harm the deep temporal muscle blood vessels. The graft was inserted over the glenoid fossa and sutured with the zygomatic periosteum (Fig. 2B). The wound was then closed in layers, and there was no need to use a vacuum pump.
Soon after the procedure, a new CT was performed (Fig. 3);physiotherapy was started 2 days after surgery and maintained for 4 months. During the five years of follow-up, no signs of ankylosis recurrence were observed; maximum mouth opening is currently 35 millimeters.
Fig. 3. Postoperative 3D computed tomography of the left temporomandibular joint.
Discussion
Management of TMJ ankylosis occurs mainly through surgical intervention; several authors agree that it is necessary to use an interpositional material to prevent TMJ re-ankylosis after arthroplasty. This particular aspect of the treatment has been the subject of numerous discussions. The temporalis muscle flap (TMF) has been used for about 100 years for restorations of the facial and craniofacial area; it is also the interposition material most commonly used for correcting TMA due to its ease of handling, proximity to the temporal joint, good functional results, successful clinical results, and minimal complications. However, the versatility of the TMF technique in supplying interpositional material is not certain and failures may occur. Inadequate removal of bone can result in reankylosis. Success in preventing reankylosis after TMJ reconstruction is dependent upon appropriate surgical technique and long-term patient compliance in undertaking frequent mandibular exercise.
The authors have proposed a slight modification of the temporal muscle flap technique, using a free graft of temporal muscle and fascia. Chossegros et al. compared a total full thickness skin graft with temporal muscle flap as interpositional material for treating temporomandibular joint ankylosis. They obtained better results (92% success) for skin graft compared with the traditional technique (83% success). The primary function of the interpositional material is to prevent re-ankylosis by eliminating contact between bone surfaces. This research suggests that a temporal muscle/fascia graft can be an option for interposition material since it is easy and faster to perform compared with the temporal muscle flap technique. Furthermore, it has the advantage of being harvested from the same surgical site.
In conclusion, the authors agree with the statement that the success in preventing reankylosis after TMJ gap arthroplasty is related primarily to the early postoperative physiotherapy, maintained long-term. The technique described above is associated with adequate bone removal and excellent intraoperative joint mobilization. A free graft harvested from temporal muscle and used as interpositional material is easy to obtain, reliable, and effective. Another advantage is minimal damage to the temporal muscle and low morbidity. Nevertheless, the findings presented here are based on a single case; controlled clinical trials must be performed to confirm this hypothesis.
Contracture of the mandible
Trismus may mean reduced opening of the jaws caused by spasm of the muscles of mastication, or it may generally refer to all causes of limited mouth opening. It is a common problem with a variety of causes, and may interfere with eating, speech, oral hygiene, and could alter facial appearance. There is an increased risk of aspiration. Temporary trismus is much more common than permanent trismus, and may be distressing and painful, and limit or prevent medical examination or treatments requiring access to the oral cavity.
Classically, the definition of trismus is an inability to open the mouth due to muscular spasm, but more generally it refers to limited mouth opening of any cause. Another definition of trismus is simply a limitation of movement. Historically and commonly, the term lock jaw was sometimes used as a synonym for both trismus and tetanus. Definitions from popular medical dictionaries vary, e.g.:
“a motor disturbance of the trigeminal nerve, especially spasm of the masticatory muscles, with difficulty in opening the mouth (lockjaw); a characteristic early symptom of tetanus.”
“a firm closing of the jaw due to tonic spasm of the muscles of mastication from disease of the motor branch of the trigeminal nerve. It is usually associated with general tetanus. Also called lockjaw.”
“a prolonged tonic spasm of the muscles of the jaw.”
“spasms of the muscles of mastication resulting in the inability to open the oral cavity; often symptomatic of pericoronitis.”
Normal mouth opening ranges from 35 to 45 mm. Males usually have slightly greater mouth opening than females. Trismus is derived from the Greek word trismos meaning “a scream; a grinding, rasping or gnashing”
(40-60mm)=(avg-35mm). The Normal Lateral movement is (8-12mm).
Traditionally causes of trismus are divided into intra-articular (factors within the temporomandibular joint [TMJ]) and extra-articular (factors outside the joint, see table).
Commonly listed causes of trismus |
Intra-articular: · Internal derangement of TMJ / meniscus displacement. · Fractured mandibular condyle or intracapsular fracture. · TMJ dislocation. · Traumatic synovitis. · Septic arthritis. · Osteoarthritis. · Inflammatory arthritis (e.g. rheumatoid or psoriatic). · Ankylosis. · Osteophyte formation. Extra-articular: · Trauma not involving the mandibular condyle (e.g. a fracture of another part of the mandible, fractures of the middle third of the facial skeleton, fractures of the zygoma or zygomatic arch). · Post surgical edema, e.g. removal of impacted lower wisdom teeth, or other dentoalveolar surgery. · Recent prolonged dental treatment (e.g. root canal therapy). · Following administration of inferior alveolar nerve block with local anesthetic (medial pterygoid). · Hematoma of medial pterygoid. · Acute infections of the oral tissues, especially involving the buccal space or muscles of mastication. · Odontogenic infection. · Peritonsillar abscess. · Acute parotitis, e.g. mumps. · Pericoronitis. · Submasseteric abscess. · Tetanus. · Tetany. · Local malignancy. · Myofascial pain / temporomandibular joint disfunction. · Radiation fibrosis. · Fibrosis from burns. · Submucous fibrosis. · Systemic sclerosis. · Myositis ossificans. · Coronoid hyperplasia. · Malignant hyperpyrexia. · Epidermolysis bullosa. · Drug associated dyskinesia. · Psychotic disturbances, hysteria. |
Intra-Articular Causes
Ankylosis
· True Bony Ankylosis: can result from trauma to chin, infections and from prolonged immobilization following condylar fracture
· Treatment- several surgical procedures are used to treat bony ankylosis, E.g.: Gap arthroplasty using interpositional materials between the cut segments.
· Fibrous Ankylosis: usually results due to trauma and infection
· Treatment- trismus appliances in conjunction with physical therapy.
Arthiritis Synovitis
Meniscus Pathology
Extra-Articular Causes
Infection
· Odontogenic- Pulpal
· Periodontal
· Pericoronal
· Non-Odontogenic- Peritonsillar abscess
· Tetanus
· Meningitis
· Brain abscess
· Parotid abscess
· The hallmark of a masticatory space infection is trismus. Or infection in anterior compartment of lateral pharyngeal space results in trismus. If these infections are unchecked, can spread to various facial spaces of the head & neck and lead to serious complications such as cervical cellulitis/ mediastinitis.
· Treatment: Elimination of etiologic agent along with antibiotic coverage
· Trismus or lock jaw due to masseter muscle spasm, can be a primary presenting symptom in tetanus, Caused by clostridium tetani, where tetanospasmin (toxin) is responsible for muscle spasms.
· Prevention: primary immunization (DPT)
Dental Treatment
· Dental trismus is characterized by a difficulty in opening the jaw. It is a temporary condition with a duration usually not longer than two weeks. Dental trismus results from some sort of insult to the muscles of mastication, such as opening the jaw for a period of time or having a needle pass through a muscle. Typical dental anesthesia to the lower jaw often involves the needle passing into or through a muscle. In these cases it is usually the medial pterygoid or the buccinator muscles.
· Oral surgery procedures, as in the extraction of lower molar teeth, may cause trismus as a result either of inflammation to the muscles of mastication or direct trauma to the TMJ.
· Barbing of needles at the time of injection followed by tissue damage on withdrawal of the barbed needle causes post-injection persistent paresthesia, trismus and paresis.
· Treatment: in acute phase:
· Heat therapy
· Analgesics
· A soft diet
· Muscle relaxants (if necessary)
· Note: When acute phase is over the patient should be advised to initiate physiotherapy for opening and closing mouth.
Trauma
Fractures, particularly those of the mandible and Fractures of zygomatic arch and zygomatic arch complex,Accidental incorporation of foreign bodies due to external traumatic injury Treatment: fracture reduction, removal of foreign bodies with antibiotic coverage
TMJ Disorders
· Extra-capsular disorders – Myofascial Pain Dysfunction Syndrome
· Intra-capsular problems – Disc Displacement, Arthritis, Fibrosis, .. etc.
· Acute closed locked conditions – displaced meniscus
Tumors and Oral care
Rarely, trismus is a symptom of nasopharyngeal or infratemporal tumors/ fibrosis of temporalis tendon, when patient has limited mouth opening, always premalignant conditions like oral submucous fibrosis (OSMF) should also be considered in differential diagnosis.
Drug Therapy
Succinyl choline, phenothiazines and tricyclic antidepressants causes trismus as a secondary effect. Trismus can be seen as an extra-pyramidal side-effect of metaclopromide, phenothiazines and other medications.
Radiotherapy and Chemotherapy
· Complications of Radiotherapy:
· Osteoradionecrosis may result in pain, trismus, suppuration and occasionally a foul smelling wound.
· When muscles of mastication are within the field of radiation, it leads to fibrosis and result in decreased mouth opening.
· Complications of Chemotherapy:
· Oral mucosal cells have high growth rate and are susceptible to the toxic effects of chemotherapy, which lead to stomatitis.
Congenital / Developmental Causes
· Hypertrophy of coronoid process causes interference of coronoid against the anteromedial margin of the zygomatic arch.
· Treatment: Roronoidectomy
· Trismus-pseudo-camtodactyly syndrome is a rare combination of hand, foot and mouth abnormalities and trismus.
Miscellaneous disorders
· Hysteric patients: Through the mechanisms of conversion, the emotional conflict are converted into a physical symptom. E.g.: trismus
· Scleroderma: A condition marked by edema and induration of the skin involving facial region can cause trismus
Common causes
Lock-jaw caused due to muscle rigidity.
· Pericoronitis (inflammation of soft tissue around impacted third molar) is the most common cause of trismus.
· Inflammation of muscles of mastication. It is a frequent sequel to surgical removal of mandibular third molars (lower wisdom teeth). The condition is usually resolved on its own in 10–14 days, during which time eating and oral hygiene are compromised. The application of heat (e.g. heat bag extraorally, and warm salt water intraorally) may help, reducing the severity and duration of the condition.
· Peritonsillar abscess, a complication of tonsillitis which usually presents with sore throat, dysphagia, fever, and change in voice.
· Temporomandibular joint dysfunction (TMD).
· Trismus is often mistaken as a common temporary side effect of many stimulants of the sympathetic nervous system. Users of amphetamines as well as many other pharmacological agents commonly report bruxism as a side-effect; however, it is sometimes mis-referred to as trismus. Users’ jaws do not lock, but rather the muscles become tight and the jaw clenched. It is still perfectly possible to open the mouth.
Other causes
· Acute osteomyelitis
· Ankylosis of the TMJ (fibrous or bony)
· Condylar fracture or other trauma.
· Gaucher disease which is caused by deficiency of the enzyme glucocerebrosidase.
· Infection
· Local anesthesia (dental injections into the infratemporal fossa)
· Needle prick to the medial pterygoid muscle
· Oral submucous fibrosis.
· Radiation therapy to the head and neck.
· Tetanus, also called lockjaw for this reason
· Secondary to neuroleptic drug use
· Mumps
· Retropharyngeal or parapharyngeal abscess
· Seizure
Diagnostic approach
X-ray/ CT scan taken from the TMJ to see if there is any damage to the TMJ and surrounding structures.
Treatment
Treatment requires treating the underlying condition with dental treatments, physical therapy, and passive range of motion devices. Additionally, control of symptoms with pain medications (NSAIDs), muscle relaxants, and warm compresses may be used.
Splints have been used.
Temporomandibular Joint
What is TMJ ?
TMJ is an abbreviation for the anatomic structure known as the temporomandibular joint. The TMJ is the jaw joint that is located in front of the ear. This is where the lower jaw (mandible) hinges at the base of the skull to allow the mandible to open and function.
In the TMJ the mandibular condyle fits into a socket (glenoid fossa) at the base of the skull. During initial opening of the jaw, the condyle rotates in the fossa. During wide opening of the jaw, the condyle slides forward out of the fossa. In between the condyle and the glenoid fossa is a thick fibrous disc that acts like a cushion between the condyle and the fossa. The TMJ disc normally rides in unison with the condyle as it rotates and slides.
The disc is attached to the superior head of the lateral pterygoid muscle in front. Part of the superior head of the lateral pterygoid and the inferior head of the lateral pterygoid attach to the mandibular condyle in front. These muscle attachments assist in wide opening of the jaw as they pull the disc and the mandibular condyle forward. In back, the disc is attached to loose connective tissue that contains nerves and blood vessels. The entire TMJ is surrounded by a fibrous capsule.
Too often the term “TMJ” is used as a diagnostic term. Many people with pain in the area of the TMJ are told that they have “TMJ”. That is like telling someone with abdominal pain that they have “appendix”.
There are a variety of possible causes for pain in the region of the TMJ. The following is a list of possible causes of pain in the region of the TMJ:
Possible Causes of Pain in the TMJ Region |
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muscle splinting/spasm (myofascial dysfunction) |
muscle inflammation (myositis) |
headache (migraine, cluster, etc…) |
trigeminal neuralgia |
trauma to the lower jaw (fracture, disruption) |
unbalanced bite (malocclusion) |
TMJ disc dislocation |
inflammation of the TMJ (capsulitis) |
arthritic changes of the mandibular condyle |
tumor in the TMJ region |
Only a thorough physical examination and diagnostic testing, if necessary, will reveal whether or not there is a problem with the actual TMJ itself.
How do I know if I have a TMJ problem?
TMJ disorders are characterized by functional limitations of the lower jaw. Typically patients complain of not being able to opeormally or report pain with opening, speaking, or chewing. Patients may experience locking of the jaw in the open or closed position and may frequently experience clicks, pops, or grinding in the TMJ region.
Pain, alone, without functional limitations is not diagnostic of a TMJ problem. The cause or etiology for pain in the head and neck region is sometimes hard to find. Too often, when the cause of pain in the TMJ region is not readily apparent, patients are told that they have “TMJ” by default.
If you are experiencing pain in the TMJ region, only a thorough physical exam and diagnostic testing, if necessary, will determine the cause.
Who should I see if I think I have a TMJ problem?
Most patients will initially see their general dentist about a TMJ problem. Typically the dentist will then refer the patient to an oral and maxillofacial surgeon for further evaluation and recommendations for treatment. Some general dentists are experienced with TMJ disorders and may choose to diagnose the TMJ disorder and to initiate treatment themselves.
Dental specialists such as prosthodontists and orthodontists may also provide diagnosis of TMJ disorders and be involved in treatment. Medical specialists such as Ear, Nose and Throat (ENT) doctors may do the same.
Ultimately, however, if a patient needs surgical management of a TMJ disorder, an oral and maxillofacial surgeon will be involved.
How are TMJ problems diagnosed?
A proper TMJ evaluation starts with a thorough head and neck examination. A thorough medical history is also important. This includes any history of trauma to the jaw or history of previous TMJ problems and habits such as clenching and grinding the teeth.
If a TMJ problem is diagnosed, your doctor may order further tests to confirm the diagnosis and to determine the severity of the problem. The following table illustrates the tests used:
Diagnostic TMJ Test |
How the Test is Performed |
Information Gained |
Arthrogram |
X-ray sensitive dye is injected into the TMJ joint capsule and x-rays of the TMJ are taken. |
Superior test for determining disc dislocation and disc degeneration or perforation. Sometimes in cases of mild disc dislocations this test may be therapeutic in itself as the fluid dye allows the disc to “float” back into place. |
Panorex X-ray |
A panorex machine takes a two dimensional x-ray of the TMJ. |
Can determine bony changes of the condyle and fractures or severe dislocations of the condyle. Does not image soft tissue, so the position of the disc cannot be determined by this test. |
Tomograms |
A specially designed x-ray machine produces images that represent a “slice” through the TMJ. |
Can determine bony changes of the condyle. Shows the relationship of the condyle to the fossa in an open and closed position. Does not image soft tissue, so the position of the disc cannot be determined by this test. |
Magnetic Resonance Imaging |
Also known as an MRI. A non-invasive imaging technique for examining soft tissue structures. |
Images the soft tissues of the joint. Used to verify dislocations of the disc. Perforations of the disc can sometimes be seen on an MRI. |
How do you treat a TMJ problem?
Treatment of TMJ disorders depends upon the nature and severity of the TMJ problem. The following table illustrates the various ways TMJ problems are treated and the indications for those specific types of treatment.
|
Description |
Indications |
Physical therapy* |
Treatment by a physical therapist using several modalities of treatment including stretching, heat, and muscle therapy. |
Useful for muscular disorders that limit the range of motion of the jaw. Patients with severe TMJ conditions that require surgery often have secondary muscle splinting and spasm. Therefore, physical therapy is very useful in the pre and post-surgical period. |
Splint therapy* |
A hard acrylic splint is used to balance the bite (occlusion) or to reposition the lower jaw in relation to the upper jaw. |
Useful for people who grind or clench their jaws. Splints may break up the habit of clenching and grinding. Repositioning splints may help “recapture” the disc if the disruption in the joint is relatively mild. |
Arthrocentesis |
A needle is inserted into the space above the disc (superior joint space) and fluid is injected into the space. An additional needle is then placed into the superior joint space and fluid is run through the joint. |
A conservative surgical procedure that is useful for acute disc dislocations of the TMJ. Inflating the joint with fluid helps to break up any inflammatory adhesions in the joint and allows the disc to float back into proper position. Not useful in severe inflammatory conditions of the joint or chronic disc dislocation with or without disc degeneration or perforation. |
Open arthrotomy with disc repositioning |
The TMJ is opened up surgically through an incision made in front of the ear. The disc is then brought back and tacked down into proper position. |
Indicated for disc dislocations with resultant dysfunction or severe pain. This treatment may be necessary for disc dislocations when conservative methods have failed. |
Open surgery with meniscectomy |
The TMJ is opened and the disc is removed. |
This is necessary when the disc is severely deformed or perforated and beyond repair. If the joint architecture is otherwise normal, the disc does not need to be replaced. Scar tissue will form in the joint which will serve as a cushion between the condyle and the fossa. |
Open surgery with silastic implant |
When disc needs be removed, a silicone sheet is inserted into the joint space. A capsule forms around the silicone sheet. The silicone sheet is then removed in approximately 4 weeks through a small incision with local anesthesia. A capsule will have formed |
This is indicated when there has been some degeneration of the condyle or the fossa. A capsule forms around the silicone implant which is left behind after the implant is removed. This capsule serves as a cushion between the condyle and the fossa. |
Open surgery with dermal graft |
When the disc needs to be removed, it can be replaced with a dermis graft. Dermis is the layer just underneath the skin. The graft is usually taken from the abdominal wall below the waistline. |
This is indicated when there has been some degeneration of the condyle or the fossa. The dermis graft acts as a cushion between the condyle and the fossa. |
Arthroscopy* |
Similar to arthroscopy of the knee, a scope can be inserted into the TMJ in order to visualize the joint internally and to perform limited repairs. |
Arthroscopy is indicated for acute and chronic disc dislocations and inflammatory capsulitis. Relocating the disc using an arthroscope is challenging and treatment success depends on the operator’s skill with an arthroscope. Most useful for visualizing the TMJ internally without opening the joint surgically and for treating inflammatory capsulitis. |
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What are the potential complications of TMJ surgery?
The nature and degree of complications related to TMJ surgery depend on the patient’s anatomy, the degree of degeneration within the joint, and the surgical procedure itself. Patients who have had previous TMJ surgery are at higher risk for complications if additional TMJ surgery is performed on the same joint.
As with any surgical procedure, swelling, discomfort, bruising, infection and bleeding may occur. Numbness, which is usually temporary, may occur around the incision site .
Because of the close relationship between the frontal branch of the facial nerve and the TMJ, paralysis of the upper half of the face may occur on the side where the surgery was performed. This leads to the inability to raise the brow and to close the eye tightly. While this is usually temporary, in some instances problems with the frontal nerve have been known to be permanent.
As with all surgical procedures, the benefits of surgery must be weighed against the risks of surgery. This can only be determined after a thorough examination and discussion with your doctor.
Dislocation of the Temporomandibular Joint (TMJ)
What Is It?
The temporomandibular joint (TMJ), located just in front of the lower part of the ear, allows the lower jaw to move. The TMJ is a ball-and-socket joint, just like the hip or shoulder. When the mouth opens wide, the ball (called the condyle) comes out of the socket and moves forward, going back into place when the mouth closes. TMJ becomes dislocated when the condyle moves too far and gets stuck in front of a bony prominence called the articular eminence. The condyle can’t move back into place. This happens most often when the ligaments that normally keep the condyle in place are somewhat loose, allowing the condyle to move beyond the articular eminence. The surrounding muscles often go into spasm and hold the condyle in the dislocated position.
Symptoms
The jaw locks in an open position and you cannot close your mouth. The condition can cause significant discomfort until the joint returns to the proper position.
Diagnosis
The dentist bases the diagnosis on the position of the jaw and the person’s inability to close his or her mouth.
Expected Duration
The problem remains until the joint is moved back into place. However, the area can be tender for a few days.
Prevention
TMJ dislocation can continue to happen in people with loose TMJ ligaments. To keep this from happening too often, dentists recommend that people limit the range of motion of their jaws, for example by placing their fist under their chin when they yawn to keep from opening their mouths too widely. Conservative surgical treatments can help to prevent the problem from returning. Some people have their jaws are wired shut for a period of time, which causes the ligaments to become less flexible and restricts their movement. In certain cases, surgery may be necessary. One procedure, called an eminectomy, removes the articular eminence so the ball of the joint no longer gets stuck in front of it. Another procedure involves injecting medications into the TMJ ligaments to tighten them.
Treatment
The muscles surrounding the temporomandibular joint need to relax so that the condyle can return to its normal position. Many people can have their dislocated jaw corrected without local anesthetics or muscled relaxants. However, some people need an injection of local anesthesia in the jaw joint, followed by a muscle relaxant to relax the spasms. The muscle relaxant is given intravenously (into a vein in the arm). Rarely, someone may need a general anesthetic in the operating room to have the dislocation corrected. In this case, it may be necessary to wire the jaws shut or use elastics between the top and bottom teeth to limit the movement of the jaw.
To move the condyle back into the correct position, a doctor or dentist will pull the lower jaw downward and tip the chin upward to free the condyle . The doctor or dentist then guides the ball back into the socket. After the joint is relocated, a soft or liquid diet is recommended for several days to minimize jaw movement and stress. People should avoid foods that are hard to chew, such as tough meats, carrots, hard candies or ice cubes, and be careful not to open their mouths too widely.
When To Call A Professional
A TMJ dislocation requires an immediate visit to the doctor or hospital emergency room to have the joint put back in place. You may be referred to an oral and maxillofacial surgeon for treatment.
Prognosis
The outlook is excellent for returning the dislocated ball of the joint to the socket. However, in some people, the joint may continue to become dislocated. If this happens, you may need surgery.
Treatment of TMD
Discussion and examination take place at the initial consultation appointment when the patient reports time of onset, duration and intensity of pain in the affected area. The examination explores the pattern of jaw movement to detect sounds and tenderness to gentle pressure.
Further diagnostic testing is indicated the presence of jaw joint dysfunction is suspected. Further testing is designed to properly diagnose the patient’s problem and to try to reduce the signs and symptoms of the dysfunction. To determine if the lower jaw and the disc of the TM joints are in the correct position, the following diagnostic tests are used:
· Medical and Dental History as well as an examination of the teeth and the dental arches
· TMJ Health Questionnaire
Patients are asked questions regarding possible TM dysfunction symptoms. If the patient answers “yes” to any of the symptoms and “yes” to clenching and bruxing, then further tests are required to confirm the presence of a jaw joint problem (TM disorder).
· Range of Motion
Patients are checked for how wide they can open, slide left and right, move the jaw forward, and whether or not there is a deviation or deflection of the jaw upon opening. If there is a problem achieving normal range of motion, there is usually a structural problem within the joint.
· Muscle Palpation
Excessive muscle contractions and trigger points indicate a problem with the chewing muscles of mastication. This causes the muscles of the head and neck to be sore when pressed by the dentist. This usually means that the lower jaw is not in the correct position.
· TMJ X-Rays
TMJ x-rays are important to see if the condyles (top of the lower jaw bone) are too far back where they would be impinging on the nerves and blood vessels at the back of the socket where the jaw bone fits into the skull. In cases where the lower jaw is too far back, dentists find a significant reduction in the signs and symptoms of TM disorders when the jaw is repositioned forward with a splint or a functional orthopedic appliance.
Tomogram X-Ray Machine
(TMJ X-Rays)
· Computerized Joint Vibration Analysis
This is specialized equipment used to take readings of the noises or vibrations occurring within the jaw joints upon opening and closing movements. The JVA is simply a 3-minute, non-invasive test where headphones are placed on both jaw joints and the patient is instructed to open and close six times. An abnormal or dislocated joint has distinctive vibrations which can be analyzed to help diagnose the seriousness of the problem.
There are basically 5 stages of disc displacement. Ideally, if there is a jaw problem you would hope that the patient is in Stage 1 or Stage 2 where the disc can be recaptured. If the JVA reveals that the patient is in Stage 3, 4 or 5, this is a much more serious problem and the prognosis is not as good for resolution of all the symptoms.
Joint Vibration Analysis Test
Our office has the knowledge and experience needed for proper, thorough diagnosis and treatment of temporomandibular joint dysfunction.
TREATMENT
Since the teeth, jaw joints and muscles can all be involved, treatment for this condition varies. Typically, treatment will involve several phases. The first goal is to relieve the muscle spasm and pain as well as establish normal range of motion of the lower jaw. Then, your dentist must correct the way the teeth fit together. Often a temporary device known as an orthotic or splint is worn over the teeth until the bite is stabilized. Permanent correction may involve selective reshaping of the teeth, building crowns on the teeth, orthodontics or a permanent appliance to cover the teeth. If the jaw joint itself is damaged, it must be specifically treated. Although infrequent, surgery is sometimes required to correct a damaged joint. Ultimately, your dentist will stabilize your bite so that the teeth, muscles and joints all work together without strain.
Once a thorough diagnosis has been made, the dentist will begin a personalized treatment program. Patients benefit from the non-surgical, conservative treatment our office provides. Individualized therapy will include muscle spasm reduction treatments in conjunction with an easy to wear, comfortable dental orthotic, referred to as a splint. The orthotic covers the lower teeth holding the jaw in proper alignment, reducing tension in the muscles of the jaw joint, allowing healing to take place. Once pain is controlled and the jaw joint is stabilized, the bite is balanced so the teeth, muscles and joints all work together in harmony.
It is important to assess the posture of each patient to determine whether or not the shoulders, pelvis and hips are level. Photos are taken of each patient to check for the above as well as to check for forward head posture. If there is a problem with the shoulders, hips or pelvis or if one leg is longer than the other, then a referral to a chiropractor would be necessary.
To solve the problem of forward head posture which can cause cervical (neck) problems, referral to a dentist or orthodontist who uses functional jaw orthopedic appliances should be made. These appliances such as the Twin Block, MARA or Herbst Appliance successfully reposition the lower jaw forward and eliminate the forward head posture.
For most patients, treatment is divided into two stages:
1. Phase I Diagnostic Phase – Temporary Solution |
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Diagnostic Splints |
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2. Phase II Treatment Phase – Permanent Solution |
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a) |
Orthodontics |
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b) |
Crown & Bridge |
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c) |
Prosthetics |
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Full Dentures |
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Partial Dentures |
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d) |
Composite buildups posterior teeth |
PHASE I DIAGNOSTIC PHASE (Temporary Solution)
Diagnostic Splints
If there is an improper relationship between the upper and lower jaws and/or the upper and lower teeth, the patient will be required to wear temporary oral appliances (orthotic or splint). This TMJ splint is usually worn over the lower teeth until the bite and position of the lower jaw is stabilized. The objective of the lower splint is to try and establish the correct position of the mandible to the maxilla in three dimensions; namely, transverse, sagittal and vertical. The goal is to try and find a comfortable position for the lower jaw so that the patient can get some relief from the pain and muscle spasms. If the patient has a denture or a partial denture, the splint may be constructed over them similar to the method with natural teeth.
Lower Day Splint
Upper Night Appliance
Since most head, neck and shoulder pain originates from muscle instability or swelling and inflammation of the joints, we may employ various physical modalities to treat and help normalize these structures. This includes such things as transcutaneous electrical nerve stimulation (TENS), moist heat therapy, vapor coolant sprays, and infrared treatments. These joints often get very tight in people with dysfunctions and various types of mobilization or stretching techniques are employed to gaiormal function of these tissues.
Infrared Treatment for TMJ
Sometimes it will be necessary to refer patients to other health care practitioners to help relieve some of the muscle spasms including chiropractors, massage therapists, physical therapists, craniosacral therapists, etc. The patient must be made aware of the fact that, although the majority of patients do improve substantially, there are still a small number of patients whose treatment is not effective. The longer the disc is out of position anteriorly, the more the posterior ligaments get stretched and the more difficult it becomes for the posterior ligaments to reposition the disc to its correct position on the head of the condyle.
Some of these patients may have suffered traumatic injuries such as a blow to the head or have been involved in a car accident, which caused a whiplash injury. If the posterior ligaments, which help position the disc between the condyle and the temporal bone, have become stretched or torn as a result of a serious injury, then the prognosis for successful treatment is diminished. Obviously, the sooner the patient can be treated, the higher the success rate.
Near the end of Phase I, which usually lasts four months, the clinician and the patient will evaluate the success of the treatment. The patient will take the same diagnostic tests, clinical examinations, and fill out the appropriate TMJ progress report to see what improvement there is in the signs and symptoms of TM dysfunction. If the tests, including the Joint Vibration Analysis and the tomograms (TMJ x-rays), reveal that the condyle is related properly to the glenoid fossa of the temporal bone and the disc has been restored to its proper position, we would assume there would be a reduction of the signs and symptoms. A consultation appointment is held with the patient to discuss the success of Phase I and the various options for Phase II.
The vast majority of symptoms must be resolved in Phase I Diagnostic Phase prior to the initiation of Phase II Treatment Phase.
PHASE II TREATMENT PHASE JAW STABILIZATION
(Permanent Solution)
1. Orthodontics
2. Crown & Bridge
3. Overlay Partial Dentures
4. Complete Dentures
5. Partial Dentures
1. |
Orthodontics |
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Following diagnostic splint therapy to solve the problem of dislocated jaw joints, most patients have a space between their back teeth. The jaw has been moved to a temporary position where it is pain free. If the patient moves the jaw back to the original pretreatment position, the pain will come back. Therefore, to obtain a more permanent solution, orthodontics is often the treatment of choice, placing braces on the teeth and using up and down elastics to allow the back teeth to touch so the patient will be able to chew properly and with no pain. This is a more permanent solution to jaw stabilization and TMJ health. This stage can last from 12 months to 18 months depending on the severity of the case. If the space between the back teeth is large (more than 3 mm.), then this is often the treatment of choice. |
2. |
Crown & Bridge |
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If the space between the back teeth is minimal (less than 3 mm.) or if the back teeth have large restorations or missing teeth, then the best option might be to close the spaces between the back teeth with crowns and bridges. |
3. |
Overlay Partial Dentures |
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If the patient has limited financial resources, often the treatment of choice would be the placement of an overlay partial denture over the lower back teeth in order to fill the spaces between the back teeth and to stabilize the jaw (TMJ). |
4. |
Complete Dentures |
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If the patient has an old denture or dentures with the teeth all worn down, new dentures could be made with longer back teeth to fill in the spaces between the back teeth. |
5. |
Partial Dentures |
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If the patient has missing back teeth, partial dentures could be made to fill in the spaces between the back teeth. |
The important aim of correcting your bite is to ensure optimal long-term health. If you have any of the signs or symptoms mentioned, discuss them with your dentist.
Conventional Method
The physician, applying bimanual intraoral force on the mandibular molars of the patient in an inferior and then posterior direction, will reduce the dislocated condyle back into the glenoid fossa.
New Method3
The physician places one hand on each of the patient’s cheeks. On one side, the thumb is placed just above the anteriorly displaced coronoid process, and the fingers are placed behind the mastoid process to provide a counteracting force. On the other side, the fingers hold the mandible angle and the thumb is placed over the malar eminence. To reduce the dislocated jaw, one side of the mandible angle is pulled anteriorly by the fingers, with the thumb over the malar eminence acting as a fulcrum. While the mandible angle is pulled anteriorly, steady pressure is applied on the coronoid process of the other side, with the fingers behind the mastoid process
providing counteracting force. The mandible is rotated by this maneuver and the dislocated TMJ is usually reduced on one side. Once one side of the dislocation is reduced, the other side will usually go back spontaneously (Fig. 1).
FIGURE 1. In the new external method to reduce dislocated TMJ, each joint is reduced separately. Left side reduction is shown here: A, To reduce left side, the thumb is placed just above the anteriorly displaced coronoid process (black arrow),
and the fingers are placed behind the mastoid process (gray arrow). B,Simultaneously on the right side, the fingers hold and rotate anteriorly the mandible angle (black
arrow) and the thumb is placed over the malar eminence as a fulcrum (gray arrow).
Aftercare for all patients included restriction of wide mouth opening, soft diet, warm packing, and analgesics if necessary.