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of synovial joints, primarily affecting articular cartilage and sub-condylar bone; initiated by deterioration of articular soft-tissue cover and exposure of bone.
Clinical Features Crepitation sounds from joint(s) Restricted or normal mouth opening capacity Pain or no pain from joint areas and/or of
mastication muscles Occasionally, joints may show inflammatory
signs Women more frequent than men
anteriorly displaced and deformed, degenerated disc and irregular cortical outline with osteophytosis and sclerosis of condyle .
Advanced osteoarthritis and anterior disc displacement, with joint effusion
Imaging Features•Abnormal signal on T2-weighted image fromcondyle marrow: increased signal indicates marrow edema; reduced signal indicates marrow sclerosis or fibrosis
•Combination of marrow edema signal and marrow sclerosis signal in condyle most reliable sign for histologic diagnosis of osteonecrosis
•Marrow sclerosis signal may indicate advancedosteoarthritis without osteonecrosis, or osteonecrosis
Definition Inflammation of synovial membrane
characterized by edema, cellular accumulation, and synovial proliferation (villous formation).
Clinical Features Swelling of joint area, not frequently seen in TMJ Pain (in active disease) from joints Restricted mouth opening capacity Morning stiffness, in particular stiff neck Dental occlusion problems; “my bite doesn’t fit” Crepitation due to secondary osteoarthritis
After 1 year
Rheumatoid arthritis. A MRI shows completely destroyed disc, replaced by fibrous or vascular pannus and cortical punched-out erosion (arrow) with sclerosis in condyle.
Psoriatic arthropathy. Oblique coronal and oblique sagittal CT images show punched-out erosion in lateral part of condyle (arrow).
Psoriatic arthropathy. MRI shows contrast enhancementwithin bone erosion and in joint space, consistent with thickened synovium/pannus formation. OpenmouthMRI shows reduced condylar translation but normallylocated disc (and normal bone in this section)
Inflammatory arthritis
DefinitionFibrous or bony union between joint components.
DefinitionAbnormal growth of mandibular condyle; overgrowth, undergrowth, or bifid appearance.
Synovial Chondromatosis Benign tumor characterized by cartilaginous
metaplasia of synovial membrane, usually in knee, producing small nodules of cartilage, which essentially separate from membrane to become loose bodies that may ossify.
Different pathologies affecting the masticatory muscles, the temporomandibular joint (TMJ), and related structures
Affects more than 25% of the population
90% of those seeking treatment are women
Facial pains/Muscle spasms
Pain/tenderness in the muscles of mastication and joint
Cervical ROM testing Palpate joints/muscles for tenderness
Therapeutic Exercises
Manual Therapy Modalities Electromyographic
(EMG) Biofeedback Dental Splint
Improve muscular coordination
Increase muscular strength
Postural exercises Active ROM
exercises
Muscles of mastication
Cervical spine muscles
General mobility
Make a “clicking” sound with the tongue on the roof of the mouth. This slightly opens the jaw with the tongue on the palate behind the front teeth, which is the resting position of the jaw and the first portion of relaxation exercises.
Place tip of tongue on palate behind teeth and draw small circles.
Place tip of tongue on hard palate and blow air out, rolling the tongue, or making a “r r r r” sound.
Begin with proper resting position of the jaw. Teach the patient control while elevating and depressing the mandible throughout the first half of the ROM.
Keeping the tongue on the roof of the mouth, the patient opens the mouth while trying to keep the chin in midline. Use a mirror for visual reinforcement.
If the jaw deviates to one side, teach the patient to practice lateral deviation to the opposite side without creating pain or excessive motion.
Long Axis Distraction: Sitting/Supine PT positioned opposite
of affected side Use hand opposite of
affected jt. side Thumb in mouth on last
molar Apply gentle downward
pressure with thumb Hold for ~30 seconds
2-3x/session Bilaterally
Anterior Glide Same hand
placement Slightly distract
using DIP of thumb while gliding anteriorly
Oscillate for 30 seconds
Lateral Glide Thumb on tongue side of last molar Use whole hand to oscillate laterally
Medial Glide Stand on affected side Thumb on lateral side of last molar Glide medially
Avoid: Large bites Excessive chewing Removing food from
teeth with tongue Gum chewing Chewy foods: bagels,
sandwiches, steak, ice, crunchy fruits/vegetables, caramel, nuts etc.
Relaxation techniques to reduce stress/muscle tension
Maintain good posture
5-10 % dx w/TMJ Dysfunction fail to have relief of medical tx, and require surgery
Antiinflammatories, soft diet, hot compresses, muscle relaxants
Specific Suture & Blades (# 11) Medications on field (name & purpose) Catheters & Drains: n/a Drapes: head turban for initial drape; pad pt forehead
with a folded towel; plastic adhesive wound drape to cover ET tube and mouth; split sheet and large sheet for body drape, (laser: 4 wet towels around pt’s face; moistened cotton in external auditory canals, irrigation collection pouch at base of ear and TMJ)
2 60 mL syringes 4 10 mL syringes 1 1-mL syringe Needles: 18 g, 21 g, 25 g Skin stapler Eye pads Sterile water and saline 1000 mL Lactated Ringers for irrigation 30 in extension tubing Stopcock
General: suction, Lactated Ringer’s IV bag for irrigation, marking pen
Light cord, camera & cord, small joint rotary shaver
General: suction system Specific
Monitor/light source/camera tower, shaver control unit, IV pole for irrigant
Fluid infusion system Bipolar ESU Holmium laser
Irrigation solution is injected into the joint space to distend the capsule LR solution is preloaded in syringe w/needle attached.
After small stab incision is placed, surgeon inserts a sheath w/sharp obturator into superior joint space. After space is entered, the sharp is replaced with a dull obturator to further direct the sheath into the joint without damaging the intraarticular tissue or adjacent neurovascular structures. #11 blade with # 7 handle will be ready Trocar/cannula is preassembled. Expect trocor to be
returned. Be prepared to assist with connections of video/light cord connections.
Irrigation is infused into the joint LR solution is connected to the cannua via
extension tubing Joint is examined
Prepare to operate remote control for still photos
If functional surgery is needed, a second stab wound is made Pass skin knife. Prepare additional equipment
(probe, shaver, grasper) Final visual inspection is performed
Additional photos may be taken
Cannuale are removed and excess fluid removed Prepare for closure; count
Wound is closed and dressing placed Pass suture; prepare dressings, reorganize
equipment & supplies if procedure is bilateral Steps may be repeated contralaterally