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Ankylosis of temporomandibular joint: etiology, pathogenesis, classification, clinical features, diagnosis and treatment of ankylosis. Contracture of the mandible: etiology, classification, clinical features, differential diagnosis, treatment, prevention. Dislocations mandible: etiology, symptoms, diagnosis, treatment.

introduction

INTRODUCTION

Temporomandibular joint,

(TMJ), an essential joint of the face, required for speech andnutrition; a synovial joint formed by the mandibular fossa of the temporal bone and the head of the condyle of the mandible with an intervening articular disc. The joint surface is completely covered by a thick fibrous capsule that allows for range of movements.

Ankylosis (joint stiffness)

is the pathological fusion of parts of a joint resulting in restricted movement across the joint

Ankylosis of the Temporomandibular joint, an arthrogenic disorder of the TMJ, refers to restricted mandibular movements (hypomobility) with deviation to the affected side on opening of the mouth.

incidence

INCIDENCE

Affects all age group but more in the first decade of life (0 – 10 years)

There’s equal male and female distribution

Almost all cases are unilateral.

pathophysiology

PATHOPHYSIOLOGY

TRAUMA

Extravasation of blood into the joint space

haemarthrosis

Calcificatiion and obliteration of the joint space

Extra-capsular ankylosis

Intra-capsular ankylosis

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Extra-capsular ankylosis

    • There’s an external fibrous encapsulation with minimal destruction of the joint itself.

Intra-capsular ankylosis

There’s destruction of the meniscus and flattening of the temporal fossa

thickening and flattening of the condylar head and a narrowing of the joint space.

Opposing surfaces then develop fibrous adhesions that inhibit normal movements and finally, may become ossified.

clinical features

CLINICAL FEATURES

Inability to open the jaws

In unilateral ankylosis, the lower jaws shifts towards the affected side on opening of the mouth

In severe cases, there is complete immobilization

There may be Abnormal forward protrusion of the mandible as the excess tissues occupies the space

Facial deformity

Others are related to the underlying cause of the ankylosis

Fever

Pain

Other bones and joints deformities

sequelae of tmj ankylosis

SEQUELAE OF TMJ ANKYLOSIS

Speech impairment

Facial growth distortion

Nutritional impairment

Respiratory disorders

Malocclusion

Poor oral hygiene

Multiple carious and impacted teeth

management

MANAGEMENT

Non surgical management

Surgical treatment

surgical management

SURGICAL MANAGEMENT

Aims and Objectives of surgery

To release ankylosed mass and creation of a gap to mobilize the joint

Creation of functional joint (improve patient’s oral hygiene, nutrition and good speech)

To reconstruct the joint and restore the vertical height of the ramus

To prevent re-occurrence

To restore normal facial growth pattern

To improve esthetic appearance of the face (cosmetic reason)

Physiotherapy follow-up

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SURGICAL MANAGEMENT……

Procedures

Condylectomy

Gap arthroplasty

Interpositional arthroplasty

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SURGICAL MANAGEMENT……

  • CONDYLECTOMY
  • This procedure is usually indicated when the joint space is obliterated with the deposition of fibrous bands; but, there hasn’t been much deformity of the condylar head. Usually employed in cases of fibrous ankylosis.
  • Pre-auricular incision is made
  • Horizontal cut carried is out at the level of the condylar neck
  • The head (condyle) should be separated from the superior attachment carefully
  • The wound is then sutured in layers
  • The usual complication of this procedure is an ipsilateral deviation to the affected side. And anterior open bite if the procedure was bilaterally.
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SURGICAL MANAGEMENT……

  • GAP ARTHROPLASTY
  • This procedure is employed in an extensive bony ankylosis.
  • The section here consists of two horizontal osteotomy cuts
  • And removal of bony wedges for creation of a gap between the roof of the glenoidfossa and the ramus of the mandible.
  • This gap permits mobility
  • The minimum gap should be 1cm to avoid re-ankylosis
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SURGICAL MANAGEMENT……

  • INTERPOSITIONAL ARTHROPLASTY
  • This is actually an improvement/modification on gaparthroplasty
  • Currently the surgical protocol of choice
  • Materials are used to interpose between the ramus of the mandible and base of the skull to avoid re-ankylosis
  • The procedure involves the creation of gap, but in addition, a barrier is inserted between the two surfaces to avoid reoccurrence and to maintain the vertical height of the ramus
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INTERPOSITIONAL ARTHROPLASTY

SURGICAL MANAGEMENT……

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SURGICAL MANAGEMENT……

MATERIALS USED IN INTERPOSITIONAL ARTHROPLASTY

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SURGICAL MANAGEMENT……

  • Advantages of this procedure (interpositional arthroplasty)
  • Autografts, such as skin, temporalis muscle, or fascia lata, are presently considered the materialofchoice for interposition.
  • In more recent years, a pedicledtemporalismyofascial or temporalis fascia flap has been advocated in TMJ surgery to treat the TMJ ankylosis.
  • Advantages of these flaps in TMJ reconstruction include
    • close proximity to the TMJ without involving an additional surgical site,
    • adequate blood supply,
    • autogenous origin grafts can be used,
    • and maintenance of attachment to the coronoid process, which provides movement of the flap during function, simulating physiologic action of the disc.
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SURGICAL MANAGEMENT……

Advantages of this procedure (interpositional arthroplasty)

Post -OP

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SURGICAL MANAGEMENT……

  • Complications of the surgery
  • Anaesthesia
  • Aspiration of blood clot, tooth or foreign body
  • Falling back of the tongue causing airway obstruction
  • Intra-Operative
  • Haemorrhage (damage of any superficial temporal vessels, transverse facial artery, etc)
  • Damage to the external auditory meatus
  • Damage to the Zygomatic and temp. branch of facial nerve
  • Damage to the Glenoidfossa
  • Damage to the Auriculotemporal nerve
  • Damage to the Parotid gland
  • Damage to the teeth
  • Post Operative
  • infection
  • open bite
  • re-occurrence of ankylosis
forms of contracture
Forms of contracture:
  • Inflammatory contracture
  • Muscular contracture
  • Arthrogenous contracture
  • Fibrous contracture
  • Neurogenic contracture
intra articular causes
Intra-Articular Causes
  • Ankylosis
  • Arthiritis Synovitis
  • Meniscus Pathology
extra articular causes
Extra-Articular Causes

Infection:

Odontogenic- Pulpal

  • Periodontal
  • Pericoronal

Non-Odontogenic- Peritonsillar abscess

  • Tetanus
  • Meningitis
  • Brain abscess
  • Parotid abscess
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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
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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.
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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.
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Congenital / Developmental Causes

  • Hypertrophy of coronoid process causes interference of coronoid against the anteromedial margin of the zygomatic arch.
  • 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
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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.
  • Peritonsillarabscess, a complication of tonsillitis which usually presents with sore throat, dysphagia, fever, and change in voice.
  • Temporomandibular joint dysfunction (TMD).[8]
  • 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.[8]
  • Submucous fibrosis.
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Dislocation

Dislocation is a complete separation of the articular surfaces with fixation in an abnormal position.

Anterior dislocation of the condyle in which the normal anatomic relationships within the joint have been completely disrupted occurs with the condyle displaced and fixed anterior to the articular eminence.

causes
Causes:
  • Deep yawning
  • Prolong Dental procedures
  • Airway manipulation particularly in an anaesthetised patient.
  • Dislocation can occur during laryngoscopy, transoral fiberoptic bronchoscopy and intubation.
clinical features4
Clinical features:
  • TMJ dislocation may occur with trauma, but most often follows extreme opening of the mouth during yawning, laughing, singing, vomiting, or dental treatment .
  • Dislocation also can result from dystonic reactions to drugs .
  • Symmetric mandibular dislocation is most common, but unilateral dislocation with the jaw deviating to the opposite side also can occur.
  • TMJ dislocation is painful and frightening for the patient.
on examination
On examination:
  • The patient is unable to close the mouth and there is excessive salivation .
  • A depression may be noted in the preauricular area.
  • Palpation of the TMJ reveals one or both of the condyles trapped in front of the articular eminence and spasm of the muscles of mastication.
  • Patients prone to mandibular dislocation include those with an anatomic mismatch between the fossae and articular eminence, weakness of the capsule and the temporomandibular ligaments, and torn ligaments.
  • Patients who have had one episode of dislocation are predisposed to recurrence .
diagnosis
Diagnosis:
  • The dentist bases the diagnosis on the position of the jaw and the person's inability to close his or her mouth.
  • Radiographs of the TMJ are not always necessary, but should be obtained to exclude condylar fracture if the dislocation is related to trauma
  • The problem remains until the joint is moved back into place. However, the area can be tender for a few days.
treatment
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.
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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 advice not to open their mouths too widely.
prevention
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.
  • Eminectomy removal of the articular eminence so that 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.
prognosis
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, needs surgery.