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etiology, pathogenesis,
classification, clinical
features, diagnosis and
treatment of ankylosis.
Contracture of the mandible:
etiology, classification,
clinical features, differential
diagnosis, treatment,
prevention. Dislocations
mandible: etiology,
Temporomandibular joint,
(TMJ), an essential joint of the face, required for speech and
nutrition; a synovial joint formed by the mandibular fossa of
the temporal bone and the head of the condyle of the
mandible with an intervening articular disc. The joint surface
is completely covered by a thick fibrous capsule that allows
for range of movements.
Trauma
-At birth (with forceps)
-Blow to the chin (causing
haemarthrosis)
-Condylar fracture
Systemic disease
-Small pox
-Ankylosing spondylitis
-Syphilis
-Typhoid fever
-Scarlet fever
Others
-Malignancies
-Post radiology
-Post surgery
-Prolonged trismus
TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis
Extra-capsular ankylosis
Intra-capsular ankylosis
Theres destruction of the
Extra-capsular ankylosis
Theres an external fibrous
Fibrous Ankylosis
Bony ankylosis
pain
contralateral side
No radiographic findings other
limitation of contralateral
condylar translation
lateral movment
Theres a radiographic
evidence of bone
proliferation
Speech impairment
Facial growth distortion
Nutritional impairment
Respiratory disorders
Malocclusion
Poor oral hygiene
Multiple carious and impacted
teeth
Non
surgical
management
Surgical treatment
the joint
Creation of functional joint (improve patients oral hygiene,
ramus
To prevent re-occurrence
To restore normal facial growth pattern
To improve esthetic appearance of the face (cosmetic reason)
Physiotherapy follow-up
Procedures
1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty
CONDYLECTOMY
This procedure is usually indicated when the joint space is obliterated
with the deposition of fibrous bands; but, there hasnt been much
deformity of the condylar head. Usually employed in cases of fibrous
ankylosis.
Pre-auricular incision is made
Horizontal cut carried is out at the level of the condylar neck
The head (condyle) should be separated from the superior attachment
carefully
The wound is then sutured in layers
The usual complication of this procedure is an ipsilateral deviation to
the affected side. And anterior open bite if the procedure was
bilaterally.
GAP ARTHROPLASTY
This procedure is employed in an extensive bony ankylosis.
The section here consists of two horizontal osteotomy cuts
And removal of bony wedges for creation of a gap between
the roof of the glenoid fossa and the ramus of the mandible.
This gap permits mobility
The minimum gap should be 1cm to avoid re-ankylosis
INTERPOSITIONAL ARTHROPLASTY
INTERPOSITIONAL ARTHROPLASTY
Heterogenous
Alloplastic
I.
I.
chromatised
submucosa of pigs
bladder
II.
lyophilized bovine
cartilage
Nonmetallic: silastic,
Teflon, acrylic, nylon,
ceramic
Temporalis muscles
(interpositional arthroplasty)
(interpositional arthroplasty)
Forms of contracture:
Inflammatory contracture
Muscular contracture
Arthrogenous contracture
Fibrous contracture
Neurogenic contracture
Intra-Articular Causes
Ankylosis
Arthiritis Synovitis
Meniscus Pathology
Extra-Articular Causes
Infection:
Odontogenic- Pulpal
Periodontal
Pericoronal
Non-Odontogenic- Peritonsillar abscess
Tetanus
Meningitis
Brain abscess
Parotid abscess
Trauma
Fractures, particularly those of the mandible
and Fractures of zygomatic arch and zygomatic
arch complex,Accidental incorporation of foreign
bodies due to external traumatic injury
Treatment: fracture reduction, removal of foreign
bodies with antibiotic coverage
TMJ Disorders
Extra-capsular disorders Myofascial Pain
Dysfunction Syndrome
Intra-capsular problems Disc Displacement,
Arthritis, Fibrosis, .. etc.
Acute closed locked conditions displaced
meniscus
Common causes
Lock-jaw caused due to muscle rigidity.
Pericoronitis (inflammation of soft tissue around impacted third molar)
is the most common cause of trismus.
Inflammation of muscles of mastication. It is a frequent sequel to
surgical removal of mandibular third molars (lower wisdom teeth). The
condition is usually resolved on its own in 1014 days, during which
time eating and oral hygiene are compromised. The application of heat
(e.g. heat bag extraorally, and warm salt water intraorally) may help,
reducing the severity and duration of the condition.
Peritonsillar abscess, a complication of tonsillitis which usually presents
with sore throat, dysphagia, fever, and change in voice.
Temporomandibular joint dysfunction (TMD).[8]
Trismus is often mistaken as a common temporary side effect of many
stimulants of the sympathetic nervous system. Users of amphetamines
as well as many other pharmacological agents commonly report
bruxism as a side-effect; however, it is sometimes mis-referred to as
trismus. Users' jaws do not lock, but rather the muscles become tight
and the jaw clenched. It is still perfectly possible to open the mouth.[8]
Submucous fibrosis.
Dislocation
Dislocation is a complete
separation of the articular
surfaces with fixation in an
abnormal position.
Causes:
Deep yawning
Prolong Dental procedures
Airway manipulation particularly in an
anaesthetised patient.
Dislocation can occur during laryngoscopy,
transoral fiberoptic bronchoscopy and
intubation.
Clinical
features:
TMJ dislocation may occur with trauma, but most
often follows extreme opening of the mouth
during yawning, laughing, singing, vomiting, or
dental treatment .
Dislocation also can result from dystonic reactions
to drugs .
Symmetric mandibular dislocation is most
common, but unilateral dislocation with the jaw
deviating to the opposite side also can occur.
TMJ dislocation is painful and frightening for the
patient.
On
examination
:
Diagnosis:
The dentist bases the diagnosis on the position
of the jaw and the person's inability to close his
or her mouth.
Radiographs of the TMJ are not always
necessary, but should be obtained to exclude
condylar fracture if the dislocation is related to
trauma
The problem remains until the joint is moved
back into place. However, the area can be tender
for a few days.
Treatment :
The muscles surrounding the temporomandibular joint
need to relax so that the condyle can return to its normal
position.
Many people can have their dislocated jaw corrected
without local anesthetics or muscled relaxants. However,
some people need an injection of local anesthesia in the
jaw joint, followed by a muscle relaxant to relax the
spasms.
The muscle relaxant is given intravenously (into a vein in
the arm). Rarely, someone may need a general anesthetic
in the operating room to have the dislocation corrected.
In this case, it may be necessary to wire the jaws shut or
use elastics between the top and bottom teeth to limit the
movement of the jaw.
Prognosis:
The outlook is excellent for returning the
dislocated ball of the joint to the socket.
However, in some people, the joint may continue
to become dislocated , If this happens, needs
surgery.