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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 experience assoc with actual / potential tissue damage, &/ described in terms of such damage Loeser 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 stimulation 2. Neuropathic pain is caused by damage or disease affecting the central or peripheral nervous system 3. 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 PAIN persistent / recurrent pain, lasting beyond usual course of acute Illness/injury, />6 mths, & adversely affecting pat’s wellbeing Loeser 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 tensiontype headache, facial pain, and abdominal pain, indicate higher prevalence rates in adult women than in adult men. Gender variations in clinical pain experience- Unruh A Pain 65:123-167, 1996 IMPORTANCE OF PAIN 1. Makes one withdraw from potentially damaging situations 2. Protect a damaged body part while it heals 3. Trains one to avoid painful situations in the future PAIN FACTS 1. Most pain resolves promptly once the painful stimulus is removed 2. Some pain persists despite removal of the stimulus 3. Sometimes pain arises in the absence of any detectable stimulus, damage or disease The Pain Gate Control Theory NO INPUT – GATE IS CLOSED 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 NORMAL 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). GATE CONTROL THEORY 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). The Pain Gate Control Theory chemicals +/- 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 - touch 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. 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. 2. 3. 4. 5. 6. 7. ARTHRALGIA MYALGIA SPLINTING TRAUMATIC TRISMUS CONTRACTURE DISC DISPLACEMENT WITH REDUCTION DISC DISPLACEMENT WITHOUT REDUCTION DIAGNOSIS II 1. 2. 3. 4. 5. 6. 7. 8. TENDONITIS LATERAL CAPSULITIS RETRODISCITIS SUBLUXATION DISLOCATION OSTEOARTHROSIS OSTEOARTHRITIS 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 bone Attachment: lateral surface of angle & ramus of mandible Action: closes jaw deep masseter - vertical force superficial masseter - vertical & slightly anterior force perpendicular to occlusal plane of molars MUSCLES OF MASTICATION TEMPORALIS Origin: temporal fossa Attachment: coronoid Action: 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 fossa Attachment: medial surface of angle of mandible Action: closes jaw and moves mandible to opposite side MUSCLES OF MASTICATION LATERAL PTERYGOID • Superior Pterygoid (LPS) Origin: infratemporal surface Attachment: capsule, disc & condylar neck Action: stays active during power stroke and closing MUSCLES OF MASTICATION LATERAL PTERYGOID • Inferior Pterygoid (LPI) Origin: lateral pterygoid plate Attachment: neck of condyle Action: protrudes the mandible stays active during opening NECK MUSCULATURE • Sternonucleidomastoid • Trapezius • Intrinsic Neck Muscles MUSCLE PAIN & INJURY MYALGIA - subjective complaint of pain in the muscles - tenderness on palpation - if more diffuse - it is called fibromyalgia* • EMG studies Franks, 1965, Schwartz, 1968, Stohler, 1985, Yemm, 1971 • Thermography Berry, 1974, Kopp, 1981 *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 Females = 53.6 to 64.4 kg = 35.8 to 44.9 kg 2. Range of maxillary force on incisor & molar 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 (Howell & Manly, 1948) 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 movements Lower 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 CONDYLE LATERAL 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 CONDYLE SIZE : Anterior to posterior = 8 -10mm Medial to lateral= 15-20mm FRONTAL VIEW: TENT-SHAPED Lateral pole – is attached TM ligament & lateral part of disc Medial pole - is attached only to the disc CONTOUR: AP - very convex ; ML - gently convex Top Front TEMPOROMANDIBULAR JOINT CONDYLE POSITION Concentricity - 50-65% prevalence Non-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 CONDYLE 1. 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 FOSSA anterior 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 anteroposteriorly 4. Bordered anteriorly by post. slope of articular eminence 5. 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 fibrocartilage Unlike 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 DISC SHAPE: Ellipsoid FUNCTION: Support stabilization of condyle against articular eminence COMPOSITION: Collagen fibers Superior & inferior fibers - anterior- posterior oriented fibers Central 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 ligament Sphenomandibular ligament FUNCTION The 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 cartilage Application 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 remodelling iii. 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