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TEMPOROMANDIBULAR DISORDERS – LECTURE SERIES
ANATOMICAL
CONSIDERATIONS
Clinical A/P Chua Ee Kiam - BDS, MDS, FAMS, Dip (Counselling)
Pain
unpleasant sensory & emotional experienceunpleasant sensory & emotional experience
assoc with actual / potential tissue damage, assoc with actual / potential tissue damage,
&/ described in terms of such damage&/ described in terms of such damage
Loeser et al, 2001; Merskey H et al, 1994; Portenoy et al, 1996Loeser et al, 2001; Merskey H et al, 1994; Portenoy et al, 1996
TYPES OF PAIN
1.Nociceptive pain is caused by stimulation of peripheral nerve fibers that respond to noxious stimulation2.Neuropathic pain is caused by damage or disease affecting the central or peripheral nervous system3.Phantom pain is pain from a part of the body that has been lost or from which the brain no longer receives signals
4.Psychogenic pain is pain caused, increased, or prolonged by mental, emotional, or behavioral factors
CHRONIC PAINpersistent / recurrent pain, persistent / recurrent pain,
lasting beyond usual course of lasting beyond usual course of acute Illness/injury,acute Illness/injury,
/>6 mths, />6 mths,
& adversely affecting pat’s well-& adversely affecting pat’s well-beingbeing
Loeser et al, 2001; Merskey H et al, 1994; Portenoy et al, 1996Loeser et al, 2001; Merskey H et al, 1994; Portenoy et al, 1996
• Pain is expressed with gestures and facial expression
Gender differences
• Females are more affected than males• Pain is high when oestrogen is low• Common pain conditions, including migraine and tension-
type headache, facial pain, and abdominal pain, indicate higher prevalence rates in adult women than in adult men.
Gender variations in clinical pain experience- Unruh APain 65:123-167, 1996
IMPORTANCE OF PAIN
1.Makes one withdraw from potentially damaging situations2.Protect a damaged body part while it heals3.Trains one to avoid painful situations in the future
PAIN FACTS
1.Most pain resolves promptly once the painful stimulus is removed2.Some pain persists despite removal of the stimulus3.Sometimes pain arises in the absence of any detectable stimulus, damage or disease
Gate Control Theory was initially proposed in 1965 by Melzack and Wall that a gating mechanism exists in the dorsal horn of the spinal cord. Small nerve fibers (pain receptors) and large nerve fibers (“normal receptors”) synapse on the the substantia gelatinosa and Thalamus (which goes to the brain)
When no input comes in, the SG prevents T from sending signals to the brain (gate is closed)
The Pain Gate Control Theory
NO INPUT –GATE IS CLOSED
Normal somatosensory input happens when there is more large-fiber stimulation. Both the SG and the T are stimulated, but the SG prevents T from sending signals to the brain (gate is closed).
The Pain Gate Control Theory
NORMAL INPUT –GATE IS CLOSED
Nociception (pain reception) happens when there is more small-fiber stimulation or only small-fiber stimulation. This inactivates the SG ; T sends signals to the brain informing it of pain (gate is open).
GATE CONTROL THEORY
Chemicals released as a response to the pain stimuli also influence whether the gate is open or closed for the brain to receive the pain signal. This lead to the theory that the pain signals can be interfered with by stimulating the periphery of the pain site.
The Pain Gate Control Theory
chemicals
+/-
It is generally recognized that the 'Pain gate' can be shut by stimulating nerves responsible for carrying the touch signal (mechanoreceptors) which enables the relief of pain through massage techniques, rubbing, and also the application of ice packs.
The Pain Gate Control Theory
touch-
MUSCLE PAIN (MYALGIA)
Muscle pain can involve more than one muscle and also involve ligaments, tendons, and fascia, the soft tissues that connect muscles, bones, and organs.
Muscle pain also can be a sign of flu infections affecting your whole body and disorders that affect connective tissues throughout the body (SLE).
CAUSES OF MUSCLE PAIN
Injury or trauma
Overuse: using a muscle too much, too soon, too often
Tension or stress
Drugs (Cocaine & Statins for lowering cholesterol)
Infections (Flu, Malaria)
Systemic Disorders (Lupus)
DIAGNOSIS I
1. ARTHRALGIA2. MYALGIA3. SPLINTING
4. TRAUMATIC TRISMUS5. CONTRACTURE6. DISC DISPLACEMENT WITH REDUCTION7. DISC DISPLACEMENT WITHOUT
REDUCTION
DIAGNOSIS II
1. TENDONITIS2. LATERAL CAPSULITIS3. RETRODISCITIS4. SUBLUXATION 5. DISLOCATION 6. OSTEOARTHROSIS7. OSTEOARTHRITIS8. ARTHRITIS
Osteoarthrosis - The cartilage covering bones (articular cartilage) is thinned, eventually completely worn out, resulting in a "bone against bone" joint, reduced motion and pain. Osteoarthritis - the joints exposed to high stress ; pain is experienced
MAIN MUSCLES OF MASTICATION
• Masseter• Temporalis• Medial Pterygoid• Lateral Pterygoid• all innervated by mandibular division of the Trigeminal Nerve
MUSCLES OF MASTICATION
MASSETER
Origin: zygomatic boneAttachment: lateral surface of angle &
ramus of mandibleAction: closes jaw
deep masseter - vertical force
superficial masseter - vertical & slightly anterior force perpendicular to occlusal plane of molars
MUSCLES OF MASTICATION
TEMPORALISOrigin: temporal fossaAttachment: coronoidAction: anterior fibres - close jaw
posterior fibres - retract
DIAGNOSIS
TENDONITIS
complaint of pain on function pain on palpation of tendon attachments anaesthetic block eliminates the pain
MUSCLES OF MASTICATION
MEDIAL PTERYGOID
Origin: pterygoid fossaAttachment: medial surface of angle of mandibleAction: closes jaw and moves mandible to opposite side
MUSCLES OF MASTICATION
LATERAL PTERYGOID
• Superior Pterygoid (LPS)Origin: infratemporal surfaceAttachment: capsule, disc & condylar neck
Action: stays active during power stroke and closing
MUSCLES OF MASTICATION
LATERAL PTERYGOID
• Inferior Pterygoid (LPI)Origin: lateral pterygoid plateAttachment: neck of condyle
Action: protrudes the mandible
stays active during opening
NECK MUSCULATURE
• Sternonucleidomastoid
• Trapezius
• Intrinsic Neck Muscles
MUSCLE PAIN & INJURY
• EMG studiesFranks, 1965, Schwartz, 1968, Stohler, 1985, Yemm, 1971
• ThermographyBerry, 1974, Kopp, 1981
MYALGIA
- subjective complaint of pain in the muscles - tenderness on palpation - if more diffuse - it is called fibromyalgia*
*Fibromyalgia include widespread musculoskeletal pain, severe fatigue, and disturbed sleep.
DIAGNOSIS
SPLINTING guarded jaw opening due to co-contraction of muscles as a means
to avoid pain can be due to reflex splinting due to
behavioural factors
DIAGNOSIS
TRAUMATIC TRISMUS limited range of motion passive stretch - no significant increase can be CNS - induced
DIAGNOSIS
CONTRACTURE chronic resistance of a muscle to passive
stretch a result of fibrosis of supporting tendons,
ligaments and muscle fibers usually caused by trauma can be due to infection irradiation
FORCES OF MASTICATION
1. Force (Brekhus et al, 1941)
Males = 53.6 to 64.4 kg Females = 35.8 to 44.9 kg
2. Range of maxillary force on incisor & molar (Howell & Manly, 1948) 1st molars = 41.3 to 89.8 kg Central Incisors = 13.2 to 23.1 kg
3. Grinding phase (Gibbs et al, 1981)
Closure stroke averaged 26.7 kg
TEMPOROMANDIBULAR JOINT
TMJ is a freely movable joint consisting of the condyle, fossa and a disc that divides into superior and inferior cavities. These cavities are filled with synovial fluid.
Upper compartment - gliding movementsLower compartment - hinge movements
Sensory innervation – Auriculotemporal & masseteric branches of V3 of Trigerminal Nerve From SOTO USA
TEMPOROMANDIBULAR JOINT
ARTHRALGIA
complaint of joint pain joint tenderness on palpation
TEMPOROMANDIBULAR JOINT
• Condyle• Fossa• Disc• Articular surface• Disc Attachments• Capsule• Accessory Ligaments• Synovial tissues
TEMPOROMANDIBULAR JOINT
CONDYLELATERAL VIEW: IRREGULAR CONVEX
LONG AXIS:
right angle to plane of ramus
Long axes of R & L condylar heads meet anterior of foramen magnum at 140 - 160 degrees
TEMPOROMANDIBULAR JOINT
CONDYLESIZE : Anterior to posterior = 8 -10mm
Medial to lateral= 15-20mm
FRONTAL VIEW: TENT-SHAPEDLateral pole – is attached TM ligament & lateral part of discMedial pole - is attached only to the disc
CONTOUR: AP - very convex ; ML - gently convex
Top Front
TEMPOROMANDIBULAR JOINT
CONDYLE POSITION
Concentricity - 50-65% prevalenceNon-concentricity - posterior (more females)
- anterior (more males)Treatment positions for diagnosis and treatment options- Disc displacements- Reposition therapy- 4/7 position proposed by Gelb
TEMPOROMANDIBULAR JOINT
CONDYLE1. Superior and anterior surfaces are articulating areas
2. Form of condylar depends on thickness of CT (Pullinger, Bibb et al; OSOMOP, 1993)
3. Thicker layers thought to be associated with higher loads
4. Condylar asymmetry between R & L are significant in both M & F (Costa RL; Am J Phys Anthropol; 1986)
5. Condylar head is rounder in young than adults
TEMPOROMANDIBULAR JOINT
GLENOID OR MANDIBULAR FOSSAanterior wall- squamous temporal posterior wall- tympanic plate thin roof – precludes loading
Functional part is the ARTICULAR FOSSA - entirely of squamous temporal bone and covered by
articular tissue
TEMPOROMANDIBULAR JOINT
ARTICULAR FOSSA - entirely of squamous temporal bone and covered by articular tissue
1. Irregular and does not uniformly conform to the shape of the condylar head
2. Variations in form is independent to shape of condylar head (Solberg et al JOR, 1985)
3. Larger mesiolaterally than anteroposteriorly4. Bordered anteriorly by post. slope of articular eminence5. Bordered posteriorly by postglenoid tubercle (this separates
the EAM from TMJ)6. Bordered medially and superiorly by temporal bone
TEMPOROMANDIBULAR JOINT
ARTICULAR SURFACES
- are covered with fibrous connective tissue instead of hyaline cartilage
(Fibrous Connective Tissue has high tensile strength. It is found in tendons and ligaments and composed of large amounts of closely packed collagenous fibers)
-thickest at anterior superior of condyle and posterior inferior slope of the eminence
- thickness varies 0.1 to 0.5mm
TEMPOROMANDIBULAR JOINT
Cartilage is classified in three types –elastic, hyaline and fibrocartilageUnlike other connective tissues, cartilage does not contain blood vessels hence it heals very slowly
Hyaline cartilage- rich in collagen and proteoglycan- form the smooth articular surface of joints- found in larynx, nose, between ribs and sternum
Elastic cartilage- contains large amounts of elastic fibers (elastin)- stiff yet elastic- found in ear (pinna), epiglottis and Eustachian tube
Fibrocartilage- characterized by a dense network of Type I collagen (most abundant in body)- tough material that provides high tensile strength and support- contains more collagen and less proteoglycan than hyaline cartilage- present in areas most subject to frequent stress like intervetebral discs, symphysis pubis and the attachments of certain tendons and ligaments.
Proteoglycans - (are glycoproteins ) occur in connective tissues of humans.Collagen – main protein in CT in animals
TEMPOROMANDIBULAR JOINT
DISCSHAPE: EllipsoidFUNCTION: Support stabilization of condyle against articular eminence
COMPOSITION: Collagen fibersSuperior & inferior fibers - anterior- posterior oriented fibersCentral portion fibers - oriented in all 3 directions of space
POSITION: the posterior band is at the superior crest of the condyle
DISC
The disc functions as articular surfaces against both the temporal bone and the condyles and divides the joint into two compartments
It is bi-concave in structure and attaches to the neck of the condyle medially and laterally (and not to capsule or lateral ligaments
Anterior portion of disc coincides with the insertion of the superior head of the lateral pterygoid
Between the posterior portion and the posterior lamina is the “vascular knee”
Application: Disc surgery to reduce displaced Discs?
DIAGNOSIS
RETRODISCITIS
Inflammation of retrodiscal tissues condyle may be forced posteriorly retrodiscal tissues may swell forcing the
condyle forward - acute malocclusion
with heavy contact on contra-lateral
anterior teeth
DIAGNOSIS
DISC DISPLACEMENT WITH REDUCTION reproducible joint noise pain may be precipitated on jaw movement soft tissue imaging reveal the displaced disc
DIAGNOSIS
DISC DISPLACEMENT WITHOUT REDUCTION marked limited mandibular opening & pain deviation to affected side on opening marked limited laterotrusion to contralateral side no joint noise soft tissue imaging reveal the displaced disc
LOCKED
TEMPOROMANDIBULAR JOINT
DISC DISPLACEMENTS
- usually in antero-medial direction- posterior lamina is brought into articulation- conversion into a dense pad by metaplasia- or lead to clicks, locks or degenerative disease
TEMPOROMANDIBULAR JOINT
CAPSULE (outer - fibrous membrane)(inner – synovial membrane)
ATTACHMENT• lower-loosely attached to condyle on medial & lateral• upper - lateral tip of glenoid fossa on lateral & sphenoid bone on medial• well organized posterior wall which blends with the disc• thickened laterally to form the TM ligament• anterior aspect of joint - medial 1/2 no capsule• lateral 1/2 loose CT
TEMPOROMANDIBULAR JOINT
Lateral ligaments
Major ligament Temporomandibular ligament is thickened lateral part of capsule
Minor ligaments Stylomandibular ligamentSphenomandibular ligament
FUNCTIONThe ligaments define the border movements of the mandible
APPLICATION - Dislocation
Hinge Motion / Rotation
The inferior compartment allows for rotation of the condylar head around with the first 20-25 mm of the opening of the mouth.
Translation
Beyond that, the superior compartment comes into play to allow for translation and maximum opening
TEMPOROMANDIBULAR JOINT
SYNOVIAL TISSUES
ATTACHMENT : To disc
SUPERIOR CAVITY (1.2 ml) - anterior and posterior villi folds allow
for translation as much as 2 cm
INFERIOR CAVITY (0.9ml) - villi allows disc to rotate posteriorly as
condyle rotate forward
SYNOVIAL FLUID - lubricant and consist of hyaluronic acid (aids in shock absorption and transportation of nutrients), synovial cells & defence cells
Application 1- Fluid Analysis: Interleukin-1B (Kubota et al, 1977)This cytokine has the potential to initiate events that lead to loss of articular tissue, bone and cartilageApplication 2 – Jaw stuck after clenching
TEMPOROMANDIBULAR JOINT
APPLICATION
CAPSULE SURGICAL IMPLICATIONS• Dissection of capsule lateral to condyle leads to the superior cavity
• Dissection of the disc leads to the inferior cavity
• suturing disc to capsule will tense disc to the lateral lip of the glenoid fossa so disc is
deflected to the lateral pole and limit translation
DIAGNOSIS
LATERAL CAPSULITIS
tenderness at lateral pole of condyle usually follows trauma incident continuous pain originating from joint
area
REMODELLING OF THE TEMPOROMANDIBULAR JOINT
i. Progressive remodelling
ii. Regressive remodellingiii. Peripheral remodelling
Osteophytes and sclerosis is part of the remodelling process
Johnson, 1959; Solberg, 1985; Moffet, 1964; Blackwood, 1966
REMODELLING OF THE TEMPOROMANDIBULAR JOINT
1. Progressive remodelling adds new bone due to proliferation of articular cartilage and mineralization
2. Regressive remodelling causes osteoclastic resorption of subchondral bone to be filled by mesenchymal bone and replaced by cartilage, bone or both
3. Peripheral remodelling occurs at margin of articular cartilage
BIOMECHANICS OF THE TEMPOROMANDIBULAR JOINT
BASIC MOVEMENTS
1. Hinge movement –rotation of mandible around transverse axis passing through the centers of condyles(occurs in lower joint compartment between disc and condyle)
2. Sliding movement- bodily movement of mandible in anteroposterior and/or mediolateral direction(upper joint compartment between articular eminence and disc)
BIOMECHANICS OF THE TEMPOROMANDIBULAR JOINT
INITIAL OPENING PHASE
1-2 Disc rotates posteriorly aided by tension in posterior attachment & inactivty of sup. lateral pterygoid
Disc-condyle moves downwards
3 At mid open, joint is passive and unstressed
BIOMECHANICS OF THE TEMPOROMANDIBULAR JOINT
FULL OPENING PHASE
3 Gliding of disc is maximum
CLOSING OR POWER STROKE
4 Superior part of lat pterygoid active-tenses disc and cause it to move forward
Disc form s “moving wedge” to ensure full contact between joint components
BIOMECHANICS OF THE TEMPOROMANDIBULAR JOINT
FULL CLOSURE PHASE
4-1 Disc is rotated forward
Disc is stabilized by posterior attachment