1、Temporomandibular Joint (TMJ) Diseases,Youhua ZHENG,1. Evaluation,A. Introduction B. Examination C. Radiographic evaluation D. Psychologic evaluation,2. Classification of TMJ Diseases,A. Temporomandibular Disorders (Masticatory M. disorder, Structural disorder, Inflammatory disease and Osteoarthrosi
2、s ) B. Dislocation (Acute, Chronic and recurrent) C. Ankylosis D. Systemic arthritic conditions E. Developmental conditions (Hypo or Hyperplasia of Mandibular Condyle) F. Neoplasia G. Infection I. Trauma,3. Treatment,(1) Reversible treatment A. Patient education; B. Medication; C. Physical therapy;
3、D. Splints (2) Permanent occlusal modification (3) Temporomandibular joint surgeryA. Arthroscopy; B. Disk repositioning surgeryC. Disk repair or removal; D. Arthroplasty for ankylosis; E. Total join replacement,Introduction,The temporomandibular joint (TMJ) composed of the temporal bonefossa and emi
4、nencethe mandible-condyle the articular disk: a specialized dense fibrous structureseveral ligaments and numerous associated muscles.,The articular portion of the temporal bone is composed of three parts.the articular fossa, thin and may be translucent on a dry skull. This is not a major stress-bear
5、ing area.the articular eminence,thick and serves as a major functionalcomponent of the TMJ preglenoid plane, a flattened area anterior to the eminence.,Bony Structures of TMJ,Lining the inner aspect of all synovial joints, including the TMJ, are two types of tissue: articular cartilage and synovium.
6、 The space bound by these two structures is termed the synovial cavity, which is filled with synovial fluid. The articular surfaces of both the temporal bone and the condyle are covered withdense articular fibrocartilage, a fibrous connective tissue. This fibrocartilage covering has the capacity to
7、regenerate and to remodel under functional stresses. Lining the capsular ligament is the synovial membrane, a thin, smooth, richly innervated vascular tissue without an epithelium. Synovial cells, somewhat undifferentiated in appearance, serve both a phagocytic and a secretory function,Cartilage and
8、 Synovium,The articular disk composed of dense fibrous connective tissue and is nonvascularized and noninnervated, an adaptation that allows it to resist pressure,The Articular Disk,Anatomically the disk can be divided into three general regions as viewed from the lateral perspective: the anterior b
9、and, the central intermediate zone, and the posterior band. The intermediate zone is thinnest and is generally the area of function between the mandibular condyle and the temporal bone.,The articular disk is attached to the capsular ligament anteriorly, posteriorly, medially, and laterally. Some fib
10、ers of the superior head of the lateral pterygoid muscle insert on the disk at its medial aspect, apparently serving to stabilize the disk to the mandibular condyle during function. Posteriorly the articular disk blends with a highly vascular, highly innervated structure the bilaminar zone,A,B,C,D,T
11、MJ Ligament,Temporomandibular ligamentsSphenomandibular ligamentsStylomandibular ligamentsPinto ligament,Condylar process Articular fossa Articular eminence Articular disk Articular capsule and cavity Articular ligament,TMJ,Musculature,Only the four large muscles that attach to the ramus of the mand
12、ible are considered the muscles of mastication; however, a total of 12 muscles actually influence mandibular motion, all of which are bilateral.,GLENOID FOSSA,ARTICULAR TUBERCLE/ PROTUBERANCE/ EMINENCE,upper synovial cavity,CONDYLE,MUSCLE,lower synovial cavity,By J.M.LIU,By J.M.LIU,MUSCLE ACTIONS I,
13、MYLOHYHOID M,TEMPORALIS M,PTERYGOID Ms LATERAL & MEDIAL,med,lat,ELEVATION,PROTRUSION,+DEPRESSION,+ELEVATION,By J.M.LIU,Temporomandibular disorders,-A collective term embracing all the problems relating to theTMJ and related musculoskeletal structures -The group between 20-30 has the highest incidenc
14、e -Incidence rate: 20-80%, 18.3% - Masticatory M. disorder, Structural disorder Inflammatory disease and Osteoarthrosis,Temporomandibular joint dysfunction syndrome，TMJDSTemporomandibular disorders，TMD,A group of disease,The cause of evolution,Interal derangement，ID 1814年Hey W. Costen syndrome 1934年
15、，Costen Myofascial pain dysfunction MPD）1969. Laskin Temporomandibular joint pain- dysfunction syndrome PDS） 1976. Rugh,Temporomandibular joint dysfunction syndrome，TMJDS） Craniomandibular disorders Temporomandibular dysfunction syndrome TMJDS,Pathogenesis,Mental psychological Malocclusion Anatomy (
16、TMJ asymmetry) Overloading Injury Others: Cold weather, age, etc,Susceptible factor: Stress, depression, malocclusion,Induce Factor: Hard food, long time oral treatment, excessive movement,Sustaining factor: emotion, self-immune etc,Clinical Classification / Stage,Masticatory M. Disorder-Dysfunction
17、Structural disorder-internal derangement Inflammatory diseasesOsteoarthrosis (OA)-degenerative joint disease, DJD,Symptoms,Abnormal movement of TMJ Pain Clicking and crepitus Others,Clinical Presentation,Pain are the typical signs and symptomsIn the joint, pain radiating from the joint to the temple
18、, ears, side of neck and upper shoulder. The pain is typically aggravated by wide opening, chewing or other joint activities. Clicking and crepitus, popping,Clinical Presentation,Abnormal movement of TMJ because of disc interference, and masticatory muscle spasm. Incisal opening, protrusion, and con
19、tra-lateral movements are decreased and may interfere with mastication. Headaches behind and around the eyes,Clinical Examination,TMJ: Mouth opening, clicking, painlimited opening -Closed lock and open lockMuscles: Masseter, temperal, L. Pterygoid M.OcclussionPsychological,Diagnosis,History and symp
20、toms Clinical examination X- ray: Transcranial radiographs; Panoramic radiographs; tomograms TMJ arthrography TMJ computerized tomography MRI (Magnetic resonance imaging) Arthroscopy of TMJ Nuclear imaging,Diagnosis and Classification,Masticatory M. Disorder (Dysfunction): Myofascial pain, myitis, m
21、uscle spasm etc.,Structural Disorder: internal derangement Anterior disk displacement with/without reduction,Inflammatory diseases: Acute/chronic synovitis, capsulitis,Osteoarthrosis : Primary/secondary Osteoarthrosis,Differentiation,Intra-TMJ: rheumatoid arthritis, traumatic arthritis, infectious a
22、rthritis, condylar dysplasia condylar hyperplasia, tumors,Systmic Lupus Erythematosus,Extra-TMJ: Trigeminal neuralgia, glossopharyngeal neuralgia, atypical facial neuralgia,tumors,Treatment Principle,Conservative treatment, and symptom relief,Local and general treatment,Health guide, self-protection
23、, and self-treatment,Reasonable and logical treatment protocol is essential,Reversible conservative, irreersible conservative, operation,Treatment,(1) Reversible treatment A. Patient education; B. Diet; C. Medication; D. Physical therapy; E. Splints (2) Permanent occlusal modification (3) Temporoman
24、dibular joint surgeryA. Arthroscopy; B. Disk repositioning surgeryC. Disk repair or removal; D. Arthroplasty for OA; E. Total join replacement,Reversible treatment,Diet Load reduction in the TMJ is achieved by modifying the patients diet to reduce joint loading from forces of mastication. This is ac
25、hieved primarily by a non-chewing diet such as liquid or pureed food.,Reversible treatment,Pharmacologic Agents The nonsteroidal anti-inflammatory drugs (NSAID) Antidepressant medication Other medications such as tranquilizers, muscle relaxants, sedatives, and narcotic pain medications,Reversible tr
26、eatment,Physical Therapy (PT) PT in conjunction with other methods of treatment is used to relieve musculoskeletal pain and improve range of motion,Reversible treatment,Injections Injections of tender muscles, trigger areas, and/or joint spaces with local anesthetic solution relief of symptoms. Cort
27、icosteroid injection can be effective in reducing capsulitis The use of Botox to eliminate muscle spasm and reduce strength of contraction,Reversible treatment,SplintsAutoposition SplintsReposition Splints,Permanent occlusal modification,Surgical Treatment,1. Arthrocentesis 2. Arthroscopy 3. Arthrop
28、lasty (Condylotomy) 4. ArthrotomyDisk repositioning, Disk repair or removal 5. Other ProceduresCoronoidotomy/coronoidectomy Styloidectomy (Eagles Syndrome),Clinical Classification,Functional disorderStructural disorderInflammatory diseasesOsteoarthrosis,Functional disorder,L. Pterygoid M. hyperfunct
29、ion L. Pterygoid M. spasm Masticatory muscle spasm Post. band injury,Structural disorder,Anterior disk displacement with reduction Anterior disk disp1acement Without reduction Capsule enlargement and disc attachment flexibility,Inflammatory diseases,Acute/chronic synovitis, Acute/chronic capsulitis,Osteoarthrosis,Disc perforation, brokenCondyle bony destruction,
