9. TMJ INTERNAL DERANGEMENT.pptx

Temporomandibular joint, a facial joint commonly undergoes internal derangement due to the abnormal position of the articular disc in relation to the condyle. Internal derangement of the TMJ is explained in detail in this presentation.

1. INTERNAL DERANGEMENT OF TMJ AND IT’S MANAGEMENT CHANDINI RAVIKUMAR ( PG II )

2. Definition Functional Anatomy of TMJ Biomechanics of TMJ Etiology Pathogenesis Classification Clinical features Diagnosis Investigations Management CONTENTS

3. DEFINITION The term ‘temporomandibular joint (TMJ) internal derangement’ refers to clinical criteria classifying TMJ disorders but is generally used to denote an abnormal positional relationship of the articular disk to the mandibular condyle and the articular eminence (Journal of Oral Rehabilitation 2003 30; 537–543 R. EMSHOFFS.R & A. RUDISCH)

4. BONY COMPONENTS SOFT TISSUE COMPONENTS Condylar head Glenoid fossa Articular eminence Articular disc Synovial membrane Ligaments Muscles FUNCTIONAL ANATOMY OF TMJ REFERENCE : OKESON 8 TH EDITION

5. FUNCTIONAL ANATOMY OF TMJ

6. During full opening  condyle rotates along with anterior translation towards the most inferior portion of articular eminence During function  Biconcave disc remains interpostional between the condyle and the fossa with condyle remaining against the thin intermediate zone during all phases of opening and closing Normal TMJ position : 12 ‘o’ clock ( where posterior band with be at 12 and intermediate zone at 1) BIOMECHANICS OF TMJ

7. [I] The broad etiologic categories resulting in internal derangement are: • Macrotrauma —major impact to jaw, e.g., sports injury, assault • Microtrauma —parafunctional habits (clenching and bruxism) • Systemic arthropathy —rheumatoid, SLE, psoriatic arthritis, HLA B27, infective, etc. [II] An alternative framework regarding etiology is: • A normal joint subjected to overload (trauma or parafunction) • An abnormal joint subjected to normal load (rheumatoid, SLE or psoriatic arthritis, osteochondroma, chondromatosis ) ETIOLOGY REFERENCE : Oral and Maxillofacial Surgery for the Clinician

8. PATHOGENESIS PROLONGED OVERLOADING OF JOINT CHRONIC MACRO AND MICRO TRAUMA TO THE JOINT OVER STRETCHING OR LAXITY OF THE RETRODISCAL TISSUES HYPERACTIVITY OF LATERAL PTERYGOID MUSCLE MALRELATIONSHIP / IN COORDINATION OF CONDYLE-DISC MOVEMENT INTERNAL DERANGEMENT OF TMJ Oral Maxillofacial Surg Clin N Am 28 (2016) 313–333

9. Direct mechanical trauma Mechanical overloading  generation of free radicals  intercellular damage with reduction in reparative capacity 2. Hypoxia – reperfusion injury Increased intracapsular hydrostatic pressure (bruxism or clenching)  hypoxia  joint pressure reduced  free radicals are formed  intracellular damage 3. Neurogenic inflammation Compression or stretching of the nerve  pro inflammatory neuropeptides released  degeneration of structures Crit Rev Oral Biol Med 6(3):248-277(1995)

10. WILKES CLASSIFICATION STAGES STAGE I Early Painless clicking , anterior disc displacement with reduction STAGE II Early intermediate Clicking with intermittent pain and locking, anterior disc displacement with reduction STAGE III Intermediate Pain, joint tenderness, frequent and prolonged locking, restricted motion, anterior disc displacement with or without reduction, no degenerative changes STAGE IV Intermediate-late Chronic pain, restricted motion, no clicking, anterior disc displacement without reduction, degenerative bony changes, adhesions STAGE V Late Variable pain, painful/reduced function, crepitus, anterior disc displacement without reduction , advanced degenerative bony changes, gross disc deformity and /or perforation, advanced adhesions CLASSIFICATIONS

11. AAOP TAXONOMIC CLASSIFICATION FOR TMDs JOINT PAIN 2. JOINT DISORDERS 3. JOINT DISEASES 4. FRACTURES 5. CONGENITAL / DEVELOPMENTAL DISORDERS Arthralgia Arthritis Disc disorders Hypomobility disorders other than disc disorders Hypermobility disorders Degenerative joint disease Systemic arthritides Condylsis /idiopathic condylar resorption Osteochondritis dissecans Neoplasm Synovial chondromatosis Osteonecrosis DC : TMD AXIS I : PHYSICAL DIAGNOSIS Disc displacement with reduction Disc displacement with reduction and intermittent locking Disc displacement without reduction and limited opening Disc displacement without reduction without limited opening AXIS II : PSYCHOSOCIAL STATUS REFERENCE Oral Maxillofacial Surg Clin N Am 28 (2016) 313–333

12. CLINICAL FEATURES Clinically internal derangements can be categorized into four phases : Phase I (In-coordination phase) : Earliest indication No joint click or pain . However when asked to open or close the mouth, patient usually complaints of a catching sensation Phase II (Anterior disc displacement with reduction): The articular disc slips anteromedially to the head of condyle Mouth opening is accompanied by a clicking or popping sound The percussive sound is produced as the condyle passes over the posterior band and returns to a normal relationship with the disk In some patients a second clicking sound is heard during mouth closure, this is referred to as a reciprocal click and it occurs on the posterior band of the disc as it slips forward of the condyle during closing

13. Phase III (Anterior disc displacement without reduction): Here, the disk is located even further forward The condyle is unable to pass over the posterior band on attempted opening Phase IV (Disc adhesion to the articular eminence): This is the terminal stage in which due to continuous stretching, there is perforation followed by adhesion of the disc to the articular eminence. Pain, crepitus and muscle tenderness becomes a predominant feature Associated invariably with limitation of mouth opening. REFERENCE Internal derangement of temporomandibular joint etiology, pathophysiology, diagnosis and management: A review of literature Dr. Dhananjay Rathod International Journal of Applied Research 2016; 2(7): 643-649

14. DIAGNOSIS The diagnosis depends upon TAKING PROPER HISTORY : Location , Radiation, Severity, Timing , Duration and frequency of episodes ,exacerbating factors ,relieving factors, associated symptoms CLINICAL EXAMINATION : Intraoral and extraoral inspection and palpation with muscle and joint examination SEROLOGY : Rheumatoid factor, HLA- B 27, ANA , ACCP RADIOGRAPHIC EVALUATION : Conventional X-rays , CT, MRI DIAGNOSTIC LA BLOCK : Auriculotemporal nerve block REFERENCE : Oral and Maxillofacial Surgery for the Clinician

15. Synovial fluid in TMJ provides joint lubrication and stress distribution, provides nutrients and removing waste products of collagen and proteoglycan catabolism. Intra-articular pathologic conditions are associated with qualitative and quantitative changes in multiple synovial fluid biomarkers. The biomarkers identified in any given patient may enable a specific diagnosis to be made, including internal derangement, synovitis, chondromalacia, and autoimmune arthritis. Biomarkers may be used to monitor disease progression and response to treatment Oral Maxillofacial Surg Clin N Am - (2018)

16. INVESTIGATIONS 1. Transcranial view – Good visualization of both the condyle and the fossa 2. Transorbital and Reverse Towne’s projection – Depicts the entire mediolateral dimension of the articular eminence, condyle and condylar neck. 3. Tomography – Assessing the osseous changes in condyle and eminence 4. Arthrography – Includes injecting a contrast material into the joint prior to radiography. It helps in evaluating the morphology and position of the disc. However it is not commonly practiced due to the risk of infection, allergy and potential damage to the disk or capsule 5. Computerized Tomography - Assessing the bony pathologic changes in the joint 6. Magnetic Resonance Imaging –For evaluating the soft tissue of the Temporomandibular joint 7. Temporomandibular joint arthroscopy – It permits direct visualization of the interior of joint with the help of a small telescope. This technique is utilized for diagnostic and therapeutic modalities REFERENCE Internal derangement of temporomandibular joint etiology, pathophysiology, diagnosis and management: A review of literature Dr. Dhananjay Rathod International Journal of Applied Research 2016

17. MANAGEMENT REFERENCE : Oral and Maxillofacial Surgery for the Clinician Decrease joint overload Decrease pain Reduce inflammation Improvement in the range of motion Restore function Causative factors to be identified TREATMENT GOALS

18. NON-SURGICAL TREATMENT AOMSI, Oral and Maxillofacial Surgery for the Clinician, 2021

19. I. ARTHROCENTESIS 1987 - Murakami used a single needle pumping technique to create a hydraulic distention of the upper joint space. Nitzan and Dolwick subsequently modified the technique and used two needles. Indications Ant disc displacement without reduction Disc adhesion Reducible disc displacement with painful clicking and popping Arthrocentesis reduces pain by eliminating inflammatory cells from the joint space and increases the mandibular mobility by removing intra-articular adhesions, thus recovering disc and fossa space which reduces the mechanical obstruction caused by anterior disc displacement . MINIMALLY INVASIVE PROCEDURES Annals of Maxillofacial Surgery, 2019

20. Provides lysis and lavage of the upper joint space using an inflow needle, an outflow needle, and at least 300 ml Lactated Ringer’s irrigation solution. Several authors have since reported success rates of arthrocentesis in the management of internal derangement ranging from 70 to 95%

21. II. ARTHROSCOPY Minimally invasive surgery Ohnishi in 1975 The technique involves insertion of an arthroscope into the upper joint space and performance of a diagnostic sweep with lysis and lavage. Levels of TMJ arthroscopy (McCain’s terminology) Level I Arthroscopy sequence

22. 7 points of interest in TMJ Arthroscopic examination Medial synovial drape Pterygoid shadow Retrodiscal synovium Posterior slope of articular eminence and glenoid fossa Articular disc Intermediate zone Anterior recess

23. INTRA-ARTICULAR INJECTIONS Local anaesthetic Glucocorticoids Sodium hyaluronate Platelet rich plasma (PRP) Dextrose prolotherapy Autologous conditioned serum (ACS) Int. J. Environ. Res. Public Health, 2020

24. PROLOTHERAPY Prolotherapy is a regeneration or proliferation injection therapy , which aims to rehabilitate the joint structures, such as ligament or tendon, by inducing cell proliferation Prolotherapy was found to be superior to splints in reducing pain, and in improving mouth opening and clicking. Prolotherapy provides  long-term relief of symptoms , so it should be considered in patients with internal derangement of TMJ before any surgical intervention.

25. SURGICAL MANAGEMENT Disc repositioning Disc repair Discectomy alone Discectomy with autologous graft replacement Condylotomy

26. There are two main indications for disc-repositioning procedures: Patients with painful anterior disc displacement with reduction that has not responded to nonsurgical and minimally invasive procedures Patients with anterior disc displacement without reduction with persistent pain and limited mouth opening that has not responded to nonsurgical and minimally invasive procedure. I. DISC REPOSITIONING Peterson’s principles of Oral and Maxillofacial Surgery, 3 rd Edition. GOAL - to relocate the disk so that its posterior band can be returned to the normal condyle-disk fossa relationship.

27. In 1979 McCarty and Farrar first reported surgery to reposition the disc into its normal anatomic relationship relative to the condyle and fossa. One must closely inspect the disc before proceeding with its repositioning. The disc should not be distorted or placed under tension during posterior repositioning. Intraoperatively, if the disc is amenable to repositioning, it is plicated posteriorly or posterolaterally to return the anteromedially displaced disc to its more normal anatomic location. Fonseca, Oral and Maxillofacial Surgery, 3 rd Edition.

28. 3 PROCEDURES: Plication - Remodeled posterior attachment is folded on itself and the lateral tissues are approximated

29. Full thickness excision - Wedge-shaped portion of the posterior attachment is removed and the lateroposterior tissues are approximated

30. Partial thickness excision - Superior lamina of the retrodiskal tissue and posterior attachment are removed, without violation of the inferior joint space, and the lateroposterior tissues are approximated

31. II. DISC REPAIR When indicated, perforations of the disc can be managed by reparative techniques. For smaller perforations , the disc can be undermined from the surrounding soft tissue for a tension-free primary closure with a non-resorbable suture. Larger perforations of a dislocated disc require a more extensive repair, because the disc is unlikely to reduce after the margins of the perforation are excised due to more dense adhesion formation and scarring. If the disc cannot be adequately repaired, then the surgeon must make the decision to replace the disc with either an autologous or homologous graft, or perform a discectomy.

32. III. DISCECTOMY Discectomy should be considered in cases in which the disc is determined to be unsalvageable due to deformation, perforation, calcification and/or severe displacement. Partial and total discectomies have been described in the literature. The goal of surgery is to assist the patient to adapt to the pathology at hand by removing the physical impediment to movement.

33. Partial discectomy The partial diskectomy procedure is used to correct partial reducing disk displacement . The goal of the procedure is to excise the pathologic posterior attachment and that portion of the displaced atrophic/resorbed disk that represents an obstruction or is presumed to be responsible for terminal jolting. The portion of the disk that is properly positioned, usually the medial aspect of the disk , is left in place. This procedure was recently re-described under the term disk reshaping.

34. Total discectomy Total diskectomy is the procedure in which the remodeled posterior attachment and entire disk are excised. It is the most extensively used and reported surgical procedure. Total diskectomy has been used to treat the full gamut of internal derangements, without consideration for the degree of displacement of disk morphology, with generally good to excellent results. Diskectomy is indicated in those situations for which disk repositioning is not feasible because of disk atrophy, deformation, or severe degeneration.

35. IV. DISC REPLACEMENT Autogenous, homologous, and alloplastic replacements for the disk have been used following diskectomy to prevent or reduce intra-articular adhesions, osseous remodeling, and recurrent pain. In addition, the interpositional material was believed to decrease joint noises by dissipating loading forces on the osseous surfaces.

36. DISC REPLACEMENT OPTIONS AOMSI, Oral and Maxillofacial Surgery for the Clinician, 2021

37. 1. TEMPORALIS MYOFASCIAL FLAPS Uses Interpositional graft in the TMJ to avoid ankylosis Reconstruction of a joint with significant degenerative remodeling. Replacement material after discectomy Advantages Vascularized flap ; maintains a viable blood supply. Versatile ; harvested in variable thicknesses to allow for reconstruction of defects of variable sizes In unilateral cases of ID where the disc is unrepairable, it can avoid a posterior open bite on the non-operated side Disadvantages Flap necrosis Fibrosis or adhesion formation within the joint space

38. 2. AURICULAR CARTILAGE GRAFTS USES Interpositional material after discectomy Occasionally in ankylosis treatment ADVANTAGES Do not induce foreign body reactions Resists occlusal loading forces DISADVANTAGES Requires 2 nd donor site Graft may become prematurely displaced

39. 3. DERMAL GRAFTS

40. INTERPOSITIONAL MATERIAL LIMITATION Sialastic , Proplast / Teflon Foreign body reactions Ear cartilage Fragmentation and Ankylosis Fat Fragmentation and poor handling Full-thickness skin Epidermoid cyst formation Fascia and dermis Insufficient bulk and difficult to anchor Allogenic grafts Potential cross-infection and unpredictable Resorption Temporalis muscle Fibrosis and trismus Dermis-fat graft Visible scar in donor site LIMITATIONS OF INTERPOSITIONAL MATERIALS USED TO REPLACE ARTICULAR DISC FOLLOWING DISCECTOMY

41. V. CONDYLOTOMY Campbell described the first condylotomy, a closed procedure performed with a Gigli saw. Nickerson modified the procedure in 1983 by changing the osteotomy to that resembling an IVRO. Purpose : To increase joint space by allowing the mandibular condyle to move inferiorly with respect to both the articular disc and eminence. Goal : To establish a normal condyle/disc relationship, particularly for Wilkes I, II, and III (early) internal derangements. Indications : Patients with intra-articular pain or locking in association with internal derangement, and recurrent temporomandibular joint dislocation. Advantages : Extra-articular approach that avoids entry into the temporomandibular joint, short duration of the procedure, and the ability to complete the surgery in an ambulatory setting. Disadvantages : Inability to address additional sources of intra-articular pain and locking, such as synovitis, fibrous adhesions, pseudowalls , osteoarthritis, chondromalacia, and synovial chondromatosis . Furthermore, patients require arch-bars and a period of elastic maxillomandibular fixation lasting 10 days to 6 weeks.

42. V. CONDYLOTOMY

43. ARTHROPLASTY Several authors have advocated combining a disc repositioning procedure with an arthroplasty of the condyle or the articular eminence. Arthroplasty reduces the amount of posterolateral repositioning required and therefore permits repositioning of an atrophic disk The current trend, however, is to avoid removal of any normal articular bone since the postoperative healing phase already involves some loss of bone substance, which may be additive and result in occlusal disturbance. A 2 to 4 mm condylar-eminence arthroplasty can be performed with rotary or hand instruments. In some cases an arthroplasty of the eminence is essentially a lateral tuberculectomy for access and decompression of the anterior recess of the superior joint space.

44. REFERENCES 1. Internal Derangements of the Temporomandibular Joint : Oral Maxillofacial Surg Clin N Am 20 (2008) 159–168 2. Internal Derangement of the Temporomandibular Joint New Perspectives on an Old Problem : Oral Maxillofacial Surg Clin N Am 28 (2016) 313–333 3. Management of TMJ disorders and occlusion : Jeffrey okeson , 8th edition 4. Oral and Maxillofacial Surgery for the Clinician 5. Internal Derangements of the Temporomandibular Joint Pathological Variations Clyde H. Wilkes 6. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures : American Society of Temporomandibular Joint Surgeons 7. Pathogenesis of degenerative joint disease in the human temporomandibular joint : Christine L Haskin

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