Temparo mandibular joint disorders /certified fixed orthodontic courses by Indian dental academy

Temporomandibular Joint Disorders

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Temporomandibular Joint
Disorders
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Embryology- TMJ
Anatomy- TMJ
Classification – TMJ Disorders
Internal derangement
Degenerative joint disease
Chronic recurrent dislocation - TMJ


Embrylogy – TMJ
• TMJ develops between 7th & 12th week of
gestation from two separate
blastemas.(Temporal, Condyle)
• Superior to condylar blastema, a band of
mesenchymal cells defferentiate to form
articular disk.
• Temporal & Condylar blastemas
→Osteoblasts
→Membranous bone

Embrylogy – TMJ…
• In the centre of the condyle, Cartilage
develops → Secondary Cartilage
Endochondral Ossification

Subchondral Bone Formation

Enlargement of the condyle in
adulthood in adaptation to
overloading

• The developing disk is highly cellular & vascular
• It continues anteriorly with Lat.pterygoid muscle &
posteriorly by a ligament with superior end of Meckel’s
cartilage that develops in to malleus of middle ear. –
Discomalleolar ligament / Pinto’s ligament *
• In post natal life pinto’s lig. Inserts most of its fibers into
squamo tympanic fissure & loses its attachment to the
malleus.
*- Viva Question

• Pinto’s ligament: / Discomalloelar ligament
• Described by Pinto -1962
• “Fibrous link between the poasteromedial aspect of articular
disk & anterior process of malleus of middle ear seen in
fetal tm joints”
• In adults the ligament is present, but looses its attachment to
malleus
• Loughner et al -1989: dissection 14 cadaveric heads, showed
that only one had anatomic continuity to malleus


Anatomy - TMJ
• “Uniqueness” of the TMJ- Stegenga B, DeBont
LGM et al, JOMS 47:249-256 1989
• Bilateral articulation with the cranium
• Occlusion and articulation of teeth affect joint
movement and condylar positions
• Articular surfaces are fibrocartilage rather
than hyaline cartilage
• TMJ contains an articular disc

Anatomy - TMJ
• Ginglimo-di arthroidal
• Synovial Joint
• Boundaries:


Anatomy – TMJ…
 Components of TMJ
Bony
 Mandibular condyles
 Articular surfaces of
the temporal bone.
Soft tissue
 Capsule.
 Articular disc.
 Ligaments.
 Lateral pterygoid Muscle

Anatomy – TMJ…
Mandibular condyle.
 Articulating surface
 Condylar head strongly convex in the anteroposterior direction & slightly convex in the
medio-lateral direction.
 Lat. & Medial poles – check ligaments
 Condylar neck –pterygoid fovea - lateral
pterygoid muscle.

Anatomy – TMJ…
Temporal bone: - Squamous partGlenoid fossa
Articular eminence
Post glenoid tubercle


Anatomy – TMJ…
CAPSULE:
TMJ is enclosed in a thick
fibrous capsule.
Capsule attachments:
• superiorly: articular
eminence & the
circumference of the
mandibular fossa.
• Inferiorly: neck of the
condyle.
• Laterally - thickened temporo-mandibular
ligament.

Anatomy – TMJ…
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Articular disc:
Fibrocartilage,viscoelastic
Avascular,Non innervated
Bi concave
Ant. ,Post.bands &
intermed.
• Ant.—Lat.pteryg.musc
• Post.--- Bilaminar Zone
• Retrodiscal tissue

Anatomy – TMJ…
• Articular Disc:
• Medio;lateral: Check Lig.
• Superior &Inferior joint cavities

• Superior joint cavity-sliding
--- Volume --- 1.2ml
• Inferior joint cavity-rotatory
--- Volume --- o.9ml
Coronal Section - TMJ


Anatomy – TMJ…
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Articular Disk – Functions:
Shock absorber of Joint
Prevents bone- bone contact
Viscoelastic property?
Keratan sulfate,
Glycosaminoglycans - -Chondroitin 4 sulfate,
-GAG
Hyaluronic acid & Link proteins
• GAG are distributed in load bearing areas
• GAG-absorb water-allows disk to absorb stresses by deforming &
leaking water.
• On relief from stress, water content restored & loaded tissue returns
to original shape

Anatomy – TMJ…
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Ligaments:
Primary:
Capsular ligament
Diskal ligaments
Accessory:
Sphenomandibular
Stylomandibular


Anatomy – TMJ…

Sphenomandibular Ligament

Anatomy – TMJ…

Stylomandibular Ligament

Anatomy – TMJ…
• Blood supply:
• Lateral aspect- Superficial Temporal artery
• Medial & posterior aspect of disk& condyle
---Deep auricular .A,
Posterior auricular.A, Maxillary artery
Masseteric artery


Anatomy – TMJ…

“ Circulus articuli / vasculosus of william hunter.”

Anatomy – TMJ…

Arterialwww.indiandentalacademy.com
& Nerve supply

Anatomy – TMJ…
• INNERVATION OF
TMJ
• Auriculotemporal
nerve
• Masseteric nerve
• Deep temporal nerve
• Mechanoceptors
• Nociceptors

Classification of TMJ Disorders
• Masticatory muscle disorders :- MPDS
• Temporo mandibular joint disorders:
A) Disk displacement disorders /
Internal derangement
B) Degenerative joint disease
C) Chronic recurrent dislocation
D)Arthritides: Osteoarthritis,
polyarthritides
E)Ankylosis

Classification of TMJ Disorders
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E) Trauma- Condylar #
F) Tumors, Cysts
G)Infections
H)Growth disorders:
Agenesis, Hypoplasia,
Hyperplasia


Internal Derangement of
Internal Derangement Of TMJ
Temporomandibular Joint


Biomechanics of normal TMJ
• The condyle functions in both a hinge and a sliding
fashion. During full opening the condyle not only
rotates on a hinge axis but also translates forward to
a position near the most inferior portion of the
articular eminence.
• During function the biconcave disk remains
interpositioned between the condyle and fossa, with
the condyle remaining against the thin intermediate
zone during all phases of opening and closing.

• Normal tmj – Postion
of disk
Posterior band --12 o’
clock
Intermediate zone—
1 o’clock



Stretching of bilaminar zone & retrodiskal tissues
→ forward movement of disk
→ condylar translation


But..
• Prolonged overloading of Joint
• Chronic Macro & Micro trauma – joint
• Dental &/ skeletal malocclusions
• Oromandibular dyskinesias… etc
↓
• Overstretching/laxity of retrodiskal tissues
↓ +/• Hyperactivity of Lateral pterygoid muscle
↓
• Malrelationship/ in-co-ordination of condyle-disc movement
↓
•
Internal derangement of TMJ

Internal derangement of TMJ
• Hey & Davies (1814) – ― a localized
mechanical fault interfering with smooth
action of a joint‖
• Laskin (1994) -- ― A disturbance in the
normal antatomic relationship between the
disc & the condyle that interferes with
smooth movement of the joint & causes
momentary catching, clicking,popping or
locking ‖

Internal derangements of TMJ…
Staging of internal derangement – Wilkes system:
Stage-I: Early reducing disk displacement
Stage-II: Late reducing disk displacement
Stage-III: Non reducing disk displacementAcute/subacute
Stage-IV: Chronic Non reducing disk
displacementStage-V: Stage-IV + Osteoarthrosis
**Wilkes CH,

Arch Otolaryngol Head Neck Surg 115:469-457 1989

Internal derangement of TMJ…
• Clinical features & physical examination:
• Opening & reciprocal click(Stage-I or II)
• Joint Pain & tenderness to palpation, on
function
• Deviation to affected side until clicking
occurs
• Limitation of mouth opening /Deviation of
opening with lack of palpable translation
( stage-III – V)

• Clinical features & physical
examination:contd.
• Crepitus – Chronic disk displacement with
perforation, degenerative changes (StageV)


ASSESSMENT OF SOUNDS FROM TMJ



Disk displacement with reduction – (Wilkes stage-I/II)

Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings

• Stage- I
• Clincal:-no mechanical symptoms,
Reciprocal click +, no pain or limitation of ROM

• Imaging:normal tomograms, good disc contours
• Surgical: normal anatomic form, slight anterior
displacement, passive clicking


Stage-II
• Clinical: Few episodes of pain
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Imaging: Normal tomogram, slight forward
displacement & slight thickening of posterior
edge of disc
Surgical: Anterior displacement, early anatomic deformity



No Clicking

Disk displacement without reduction – (Wilkes stage-III/IV)


Disk displacement without reduction – (Wilkes stage-III/IV/V)

• ―A clicking joint doesn’t lock & a locking
joint doesn’t click‖ - Farrar et al

Current advances in Oral Surgery Vol.III- William Irby


• Stage-III:
• Clinical: Multiple episodes of pain, joint
tenderness, catching and locking, restriction of
motion, pain with function
• Imaging: Anterior displacement with moderate
to marked thickening of the posterior edge,
normal tomogram
• Surgical: Marked anatomic deformity,
displacement, adhesions, no hard tissue changes


Wilkes Stage- IV & V



• Stage-IV:
• Clincal: Chronicity with variable and episodic pain
• Imaging:abnormal tomograms, early to moderate
degenerative changes
• Surgical: Hard tissue degenerative remodeling
changing of both bearing surfaces with
osteophytes, no perforation

• Stage-V:
• Clinical: Crepitus, variable and episodic pain,
restriction of motion, functional impairment
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Imaging: Anterior displacement with
perforation, degerative arthritic changes

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Surgical: Gross degenerative changes of hard
and soft tissue, perforation of posterior attachments,
osteophytes

Pathophysiology Of Disk
displacements
• Disk displacements– Adaptive response
Pseudo disk Formation,
Remodelling of condyle..
• Chronic disk displacements
→DEGENERATIVE JOINT DISORDER


Pathophysiology Of degenerative
joint disorders
• Mechanisms of Injury:
• 1.DIRECT MECHANICAL TRAUMA:
• Trauma (mechanical overloading) → generation of free
radicals →intracellular damage & reduction in the reparative
capacity
• 2.HYPOXIA - REPERFUSION INJURY
• Increased intracapsular hydrostatic pressure (clenching &
bruxing) ----- → hypoxia.
• When the pressure in the joint is decreased and perfusion is
reestablished, free radicals are formed leading to intracellular
damage.

joint disorders
• 3.NEUROGENIC INFLAMMATION
• In cases of disk displacement the compression or
stretching of the nerve - rich retrodiscal tissue may
result in release of pro-inflammatory neuropeptides.
• The release of cytokines results in release and
activation of prostaglandins, leukotrienes, and
matrix-degrading enzymes.


joint disorders
• MECHANISMS OF TISSUE
DEGRADATION:
• 1. Enzymatic degradation
(metalloproteinases,plasma proteinases)
• 2. Nonenzymatic degradation
• (superoxide radicals, hydroxyl radicals,
NO)

“Sequential pathogenesis of degenerative changes of articular
cartilage”
Quinn JH, Oral Maxillofac Surg Clin North Am 1:47-57 1989
Stress bruxism
↓
Chronic micro trauma
↓
Compression & Shearing
↓
Chondrocyte damage --- collagenase
↓
Splitting of proteoglycan chain & water
loss
↓
Loss of cartilage resilience & water
reabsorption
↓
CHONDROMALACIA

Chronic
Non reducing Disk
displacement
Degenerative
joint disease/
Osteoarthrosis

Joint over loading

Disk
Deformation

Flattening –
condyle,articular
eminence
*Osteophytosis

Disk perforation


Degenerative changes -TMJ

Osteoarthrosis of condyle with disc displacement

Degenerative changes -TMJ

Disk perforation

Evaluation of the patient with disc
displacement & investigations
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1. Case history
2. Physical examination
3. Radiographic evaluation
a. Transcranial views
b. OPG
c. Tomograms
d. Arthrography
e. CT scans
f. MRI
g. Nuclear imaging
4. Psychologic evaluation

Treatment – Internal
derangement
Treatment for all pts with disc displacement ???
Disc displacement ---35 % asymptomatic volunteers.
• 1. Katzberg RW, Westesson PL et al “ Anatomic disorders of
the temporomandibular joint disc in asymptomatic subjects.”
J Oral Maxillofac Surg 1996; 54:147-53.
• 2. Ribeiro RF, Tallents RH et al “ The prevalence of disc
displacement in symptomatic and asymptomatic volunteers
aged 6 to 25 years. ” J Orofac Pain 1997; 11:37-47.

• Self remission of internal derangements??


Treatment – disk displacement
disorders
• Sato S, Takahashi K, et al “The natural course of nonreducing
disc displacement of the TMJ : changes in condylar mobility
and radiographic alterations at one-year follow-up.”
Int J Oral Maxillofac Surg 1998; 27:173-7.
• 44 subjects who agreed to observation without treatment
• Successful resolution - 68% @ 18 months
• Mouth opening increased from 29.7 mm to 38 mm
• Conclusion: Self reduction of displaced disc-unlikely
• Stretching & remodelling of the retrodiscal tissues, enabling the
disc to be displaced more anteriorly by the translating condyle.

Treatment – Disk displacement
disorders
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Conservative Treatment:
AIMS:
Reducing pain and discomfort
Decreasing inflammation in muscles and joints
Improving jaw function

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METHODS OF CONSERVATIVE TREATMENT:
1. Patient education
2. Medication
3. Physical therapy
4. Splints

disorders
1. PATIENT EDUCATION
• Awareness about the pathology
• Discontinuation of parafunctional habits
• Biofeedback devices
• Psychologic counseling
• Modification of diet and home exercises


disorders
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2. MEDICAL MANAGEMENT :
1. NSAIDs
2. Muscle relaxants
3. Tricyclic antidepressants
4. Steroids
5.BOTOX


disorders
• “Treatment of severe TMJ clicking with botulinum
toxin in the lateral pterygoid muscle in two cases of
anterior disc displacement .”
Merette Bakke, Eigild Moller et al
OOOE 2005;100:693-700

• EMG guided injection BTX-A & after 6
months.
• Assessment: clinical ex.,EMG, MRI
• Results:Permanent elimination of clicking
Small improvement in condyle - disc
relationship

disorders
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3.PHYSICAL THERAPY
1. Isometric jaw exercises
2. Ultrasound ( 0.7 to 1.0 watts per cm 2)
3. Spray and stretch
4. Pressure massage
5. Transcutaneous Electrical Nerve
Stimulation


4.Splint therapy – TMJ disk
displacement disorders
• RATIONALE FOR THE USE OF SPLINT
THERAPY
• “Unloading the joint” / ↑Joint space
• Reduce inflammation, increases free jaw
movement
• Decreases muscular activity
• Provides stable dental occlusion
• Possible effect in bruxism
• Placebo effect

Types of splints
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Stabilization splint
Repositioning splint
Mandibular orthopedic repositioning splint
Pivot splint
Soft splint
Bite plane splint


• PERMANENT OCCLUSAL
MODIFICATION
• Occlusal equilibration
• Prosthetic restoration
• Orthodontics
• Orthognathic surgery


• “Orthodontic treatment of TMJ disc
displacement with pain: an 18 year
follow-up”
Ugo Capurso, Ida Marini
Progress in orthodontics 2007; 8(2):240-250
68 pts with wilkes II,III– splints– orthodontic Rx
Tmj pain & Function – 1,5,10,18 yrs post Rx
Significant % of pts.-- improvement of symptoms
(73 %)

• “Temporomandibular joint dysfunction and
orthognathic surgery: a retrospective study”
Jean-Pascal Dujoncquoy, Joël Ferri et al
Head & Face Medicine 2010, 6:27
• High prevalence of TMJ disorders in dysgnathic patients.
• Patients with preoperative TMJ signs and symptoms can
improve TMJ dysfunction and pain levels be reduced by 80 %
• A percentage of dysgnathic patients who were preoperatively
asymptomatic developed TMJ disorders after surgery ---3.6 %

Surgical treatment – Disc
displacement disorders
• Indications:
• Patients unresponsive to conservative Rx
• Wilke’s stage III,IV & V


Surgical treatment Options –
Internal Derangement
1.Artrhrocentesis
2.Arthroscopy
3.Arthrotomy + Disc repair
4.Arthrotomy+ Disc repositioning
5.Arthrotomy+ Discectomy
6.Arthrotomy+ Discectomy+ Autologous
graft
7. Alloplastic joint replacement
8. Condylotomy

1.Arthrocentesis:
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Minimally invasive Sx procedure
↓ Local anestheisa +/- Sedation
Rationale:
a)Washes out inflammatory products,
b) Reduces pain mediators
c) releases adhesions, eliminates negative
pressure
d)Improves disc mobility

Arthrocentesis
• Indications:
• ID pts refractory to conservative Rx
• Effective in anterior disc displacement
without reduction
• Technique:
• Auriculotemporal nerve block
• Placing Inflow & outflow needles 18/19G in
superior joint cavity

Arthrocentesis
• Irrigation with Ringer’s lactate
• 1ml of hydrocotisone.


2.ARTHROSCOPY
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INDICATIONS OF ARTHROSCOPY
1. Internal derangement
2. Osteoarthritis
3. Arthritides
4. Pseudotumors
5. Post-traumatic complaints


ARTHROSCOPY
• Placement of cannula into superior joint
space
• Arthroscope with light source is inserted
• Video camera and monitor are connected
• Instrumentation forceps, scissors,
sutures, medication needles, cautery
probes, burs, shavers, and laser fibers

Arthroscopic procedures :

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1. Lavage
2. Lysis
3. Disk repositioning
4. Lateral capsule release
5. Synovectomy
6. Biopsy
7.Intra articular pharmacotherapy

Arthroscopy


Arthroscopy
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COMPLICATIONS :
1. Vascular injury
2. Extravasation
3. Scuffing of the cartilage
4. Broken instruments
5. Otologic complications
6. Intracranial damage
7. Infection
8. Nerve injury

Fridrich KL et al . “Prospective comparison of arthroscopy and
arthrocentesis for temporomandibular joint disorders.”
J Oral Maxillofac Surg 1996; 54:816-20.

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19 patients
GroupI: Arthroscopic lysis and lavage under general
anesthesia,
GroupII: Aarthrocentesis, hydraulic distention and
lavage under intravenous sedation.
Subjective & Objective assesment of TMJ --- 26
months
Success rates : 82% - arthroscopy
75%Arthrocentesis.
Conclusion: Both modalities - decreasing TMJ pain
Increasing mandibular range of motion


Murakami K, et al. “Short-term treatment outcome study for
the management of temporomandibular joint closed lock. A
comparison of arthrocentesis to nonsurgical therapy and
arthroscopic lysis and lavage.”
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;
80:253-7.

• 108 patients- Results of arthrocentesis, arthroscopic
surgery were comparable.
• Conclusion: Arthrocentesis was indicated for the
patient with acute TMJ closed lock who was
refractory to medication and mandibular
manipulation.

TMJ Surgery
• Surgical approaches:
• Preauricular incision (Dingman’s)
• Modified preauricular incisions
(Thoma’s,Blair’s,Al-Kayat & Bramley’s,
Popowich & Crane’s)
• Endaural incision(Lamport’s)
• Post auricular incision
• Coronal incision
• Submandibular incision(Risdon’s)
• Postramal incision(Hind’s)

Incisions on capsule


3. Arthrotomy + Disc Repair:
PLICATION:
• Chronic non reducing disc displacements
• A wedge of retrodiscal tissue is removed
• Disc is repositioned a posterior & lateral
plane
• The remaining retrodiscal tissue sutured
directly to posterior ligament


3. Arthrotomy + Disc Repair:
• DISK PLICATION:


4.Arthrotomy+ Disk repositioning
• Condylar Diskopexy:
• In Wilke’s stage –III,IV disk displacements
• Displaced disk freed in both joint spacesadhesions released
• Small hole drilled in Lat.pole of condyle
• A 2.0/3.0 non resorbable suture passed
through the hole & disk @ junction of ant.
& intermediate bands

Condylar Diskopexy


Arthrotomy+ Disk repositioning
• Temporal diskopexy:
• In Wilke’s stage IV cases with too
deformed disks
• Bur holes drilled in postero-lateral lip of
glenoid fossa
• Disk secured to roof of fossa


Diskopexy- bone anchors

―Temporomandibular joint disc
repositioning using
bone anchors: an immediate
post surgical evaluation by
MRI‖
ShanYong Zhang, XiuMing Liu
et al
BMC Musculoskeletal
Disorders 2010, 11:262

5.Arthrotomy+diskectomy
• Wilkes stage IV & V , disks with
perforations & severe degenerative
changes
• Cases with relapse of symptoms after disk
repair surgeries
• Fibrocartilagenous disk removed totally
• Condylar / fossa irregularities smoothened


6.Arthrotomy+diskectomy+autogenous
graft
• ―There is little evidence to suggest that
autogenous graft disk raplacement is
superior to no replacement at all‖
• But hypothesized rationale favouring
grafting:
a)graft provides scaffold for ingrowth of
tissue from synovium
b)May prevent degeneration that follows
diskectomy.

Arthrotomy+diskectomy+autogenous
graft
• Options:
• Auricular cartilage
• Dermis


Arthrotomy+diskectomy+autogenous
Flap


7.Condylotomy
• Popularized by Ward1952
• Creation of a
displaced condylar
neck #
• Condyle repositons
antero-inferiorly
• Unloads the posterior
attachment of disc

Hall’s Modified Condylotomy
• Vertical subcondylar
osteotomy
• Open osteotomy
procedure
• More controlled
approach to condylar
repositioning
• Less risk of total
dislocation of
condylar head

Recent advances – Rx of Internal
Recent articles on Mgmt of TMJ
Internal derangementRRecent
derangement


• “Pterygoid Plate Disjunction: Minimally Invasive
Treatment for Internal Derangement of the
Temporomandibular Joint”
Varghese Mani, Antony George et al
Asian J Oral Maxillofac Surg. 2005;17:247-255
• Patients - internal derangement of TMJ, with pain and/or trismus
and/or joint noise, underwent pterygoid plate disjunction on the
affected side.
• Subjective & Objective Assesment Pre & 18 months post-op
• Results: Pain symptoms resolved in 26 of 29 joints and diminished in the
remaining 3 joints. Trismus resolved in 22 of 24 patients and diminished in the
remaining 2 patients. Joint noise disappeared in 23 of 30 joints

• Conclusion: : Pterygomaxillary disjunction appears to be an
effective treatment for painful internal derangement of the
temporomandibular joint that is worthy of further investigation

“Pterygoid disjunction for internal derangement of
Temporomandibular joint”
Rohit Sharma.
J.Maxillofac.Oral surg.Apr-Jun2011;10(2):142-147

• As a 1* Rx modality in Wilkes I & II in 33 pts.
• Pts evaluated –Helkimo anamnestic, &
clinical dysfuntion indices, pre & post
opearively
• All the patients had improvement in Pre
operative pain & dysfunction


Randomized Effectiveness Study of Four Therapeutic
Strategies for TMJ Closed Lock
E.L. Schiffman, J.O. Look et al
J Dent Res. 2007 January ; 86(1): 58–63.

Comaprison of medical, rehabilitative, arthroscopy, arthroplaty.
Assessment of TMJ pain & funtion @ 3,6,12,18,24,60 months
• Within-group improvement for all groups
• Conlusion: Primary treatment for individuals
with TMJ closed lock should consist of medical
management or rehabilitation.
• This approach will avoid unnecessary surgical
procedures.


Chronic Recurrent dislocation of
Condyle
• Recurrent dislocation of
condyle out of the fossa
& anterior to eminece.
• Predisposing factors:
• Laxity of the ligaments
• Degenerative joint
disease
• Morphologic condition
of condyle & eminence
• Non synchronised
muscle function

Condyle- TREATMENT
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Miller & Murphy (1976)*:
1.Capsular tightening procedures
2.Creation of a mechanical obstacle
3.Direct restraint of condyle
4. Creation of new muscle balance
5.Removal of mechanical obstacle

*-Viva Q / Short Q/ Essay Q

Condyle- TREATMENT contd…
• 1.Capsular tightening procedures:
• Chemical sclerosants: Sod.teradecyl
sulfate,etc
• Capsulorrhaphy:
• Placement of horizontal mattress sutures
• Placement of vertical incision, overlapping
edges & suturing


• 2.Creation of
mechanical obstacle:
• A)Eminence
augmentation
•
i)Schadeeminence osteotomy
& silastic block
sandwich & wiring
•
ii)Glenotemporal
osteotomy

• iii)Gossarez & Dautry:

• iV)Findlay: L shaped pins

• 3.Direct restraint of condyle:
• Gordon– Fascia lata, sutured between
condyle & zygomatic arch
• Wire
• Temporal fascia


• 4.Creation of new muscle balance:
• Ward’s condylotomy
• Gould- stripping temporalis tendon to limit
anterior excursions of condyle
• Laskin- Lateral pterygoid
musc.detachment


• 5.Removal of mechanical obstacles:
• A)Annandale 1887--- Discectomy
• B)Myrhaug 1951--- Eminectomy
•


C) Condylectomy:


Recent articles – TMJ
dislocation
―Evaluation of the mechanism and principles of
management of temporomandibular
jointdislocation. Systematic review of literature and
a proposed new classification of
temporomandibular joint dislocation‖
--- Babatunde O Akinbami
-Head & Face Medicine 2011, 7:10


Key to success ---PG Exams
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A
B
C
D
E
F

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Articles / Authors
Books
Charts/flowcharts/algorithms..
Diagrams
Estimate time
Format Your answers


Suggested Reading:
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Peter.D.Quinn: Atlas of TMJ surgery
Irby:Volume -3 TMJ Disorders
Norman & Bramley- TMJ Disorders
Fonseca, Vol-4 of seven volume series: TMJ
disorders
• OMS clin. North america. –Modern surgical
management of the TMJ –Vol.18,No.3,aug.2006
• Okeson: Orofacial Pain


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Leader in continuing dental education


Temparo mandibular joint disorders /certified fixed orthodontic courses by Indian dental academy

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