口腔颌面外科学（中山大学）15颞下颌关节病课件

Temporomandibular Joint Temporomandibular Joint (TMJ) (TMJ) DiseasesDiseases Youhua ZHENGYouhua 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 Osteoarthrosis ) 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; D. Splints (2) Permanent occlusal modification (3) Temporomandibular joint surgery A. Arthroscopy; B. Disk repositioning surgery C. Disk repair or removal; D. Arthroplasty for ankylosis; E. Total join replacement Introduction The temporomandibular joint (TMJ) composed of the temporal bonefossa and eminence the mandible-condyle the articular disk: a specialized dense fibrous structure several 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-bearing area. the articular eminence, thick and serves as a major functional component 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. 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 with dense articular fibrocartilage, a fibrous connective tissue. This fibrocartilage covering has the capacity to 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 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 band, 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 fibers 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 AA B B C C DD TMJ Ligament Temporomandibular ligaments Sphenomandibular ligaments Stylomandibular ligaments Pinto 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 mandible 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 MUSCLE ATTACHMENTS II MASSETER M ELEVATION By J.M.LIU MUSCLE ACTIONS I MYLOHYHOID M TEMPORALIS M PTERYGOID Ms LATERAL 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, muscle 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 arthritis, 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, 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) Temporomandibular joint surgery A. Arthroscopy; B. Disk repositioning surgery C. 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 achieved 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 treatment 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. Corticosteroid injection can be effective in reducing capsulitis The use of Botox to eliminate muscle spasm and reduce strength of contraction Reversible treatment Splints Autoposition Splints Reposition Splints Permanent occlusal modification Surgical Treatment 1. Arthrocentesis 2. Arthroscopy 3. Arthroplasty (Condylotomy) 4. Arthrotomy Disk repositioning, Disk repair or removal 5. Other Procedures Coronoidotomy/coronoidectomy Styloidectomy (Eagles Syndrome) Clinical Classification Functional disorder Structural disorder Inflammatory diseases Osteoarthrosis Functional disorder L. Pterygoid M. hyperfunction 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, broken Condyle bony destruction Disc perforation Treatment of TMD L. Pterygoid M. hyperfunction Muscle function restoration L. Pterygoid M. spasm Muscle spasm relief: physical treatment, local block Post. band injury physical treatment, medication, local block Anterior disk displacement with reduction Repositioning splint TMJ arthroendoscope TMJ disc open reduction Anterior disk disp1acement Without reduction Manual reduction Pivot splint Artrocentesis (and viscoelasticity -increase lubrication and reduce friction -sodium hyaluronate ) TMJ arthroendoscope TMJ disc open reduction Disc perforation Conservative treatment and endoscope Disc restoration/repair Disc removal Condyle bony destruction Conservative treatment Operation ( Hyper Condylectomy, Arthroplasty ) TMJ replacement TMJ arthroendoscope TMJ Dislocation Classification: Acute, recurrent and chronic dislocation Anterial, posterial, lateral and upper dislocation Acute anterial dislocation Reason: Signs & Symptoms: 1 disturbence of mandibular movement, mouth keep opening 2 mandible protrusion, 3 malocclusion 4 Concaved pre-auricular area, the condyle can be felt under the zygomatic arch 5 X-ray film showed the position of the condyle most commonly seen Diagnosis: History, clinical examination X-ray, MRI Treatment: Mandible reduction should be conducted as soon as possible reduction: intra oral & extra oral intermaxillary reduction movement limitation: chin cap, facial band Recurrent dislocation Pathogenesis: acute - recurrent long term later pterygoid muscle dysfunction-capsule losening chronic disease muscle and ligament losening Signs & Symptoms: malocclusion disturbence of mandibular movement mandibular protrusion condyle dislocation Diagnosis: History, clinical examination X-ray, arthrograph MRI Treatment: Injection5%Sodium morrhuate operation Chronic dislocation Pathological Changes: hyperplasia, muscle spasm and adhesion Treatment: operation intermaxillary reduction and fixation Ankylosis of TMJ Classification: ankylosis of TMJ (Intra-articular) intermaxillary contracture (Extra-articular) Complex Pathogenesis Ankylosis of TMJ infection, injury and rehumatoid arthritis Intermaxillary contraction Injury, radiation, burning and gangrenopsis Pathology Intra Intra-articular ankylosis: Fibrous, Bony Extra-articular ankylosis: Tissue necrosis CT hyperplasia Scar formation contracture Symptoms: 1 Restriction of mouth pening 2 Lower face deformity: mandibular body & condylar process not well developed Normal side seemed more flatter than ankylosis side 3 Malocclusion: 4 Condyle Mobility disappear 5 X-ray: fibrous or bony ankylosis Intra-articular ankylosis Extra-articular ankylosis Symptoms: 1 Restriction of mouth pening 2 Scar or defection of oral & maxillofacial region 3 Condyle Mobility disappear 4 X-ray: normal TMJ structure Diagnosis: History clinical examination X-ray Differentiation: Intra & Extra articular ankylosis Treatment principle Intra-articular ankylosis: TMJ arthroplasty 1 Timing: age of operation 2 Position of osteoectomy 3 Management of raw surface 4 Space remaining and interpose 5 Treatment of secondary micrognathia Extra-articular ankylosis Local : Scar excision + skin graft Extensive : Scar excision + flap Prognosis Recurrent rate: 10-55% Factors related to recurrent 1 Age 2 Amount & shape of osteoecotmy 3 Interpose 4 Periosteum: 5 Post-operative training 6 Severity & operation technic obstructive sleep apnea syndrome (OSAS)obstructive sleep apnea syndrome (OSAS) Sleeping apnea 10s + Respiratory Disturbance Index(RDI) 5/hour or one night (7h) apnea & hypopnea 30 times Pathogenesis - Airway stricture and obstruction Soft tissue Hard tissue - Central regulation factor Symptoms Snoring Excessive daytime sleepness, EDS Abnormal behavior caused by sleep apnea Other symptoms caused by SaPO2 Diagnosis Airway obstruction: yes or no Position of obstruction Severity of obstruction Complication CL History Clinical examination -General examination -Respiratory & digestive tract -Crainioral maxillofacial region X-ray: cephalometric (static) SNB mandible SNA maxilla ANB mandible & maxilla PNS-P Soft palate length PAS Post Airway Space MP-H Position of Hyoid SPD Soft Palate thick