Ministry of Health of Ukraine Ukrainian Medical Stomatolgical Academy

Methodical Instructions for independent work of students during the training for the practical studies

Academic discipline Surgical stomatology Module № 6 The topic of the stadies Arthritis, arthrosis, pain dysfunction syndrome of №6 temporomandibular . Ankylosis of TMJ. Plastic surgery of TMJ. Contractures and dislocations of the lower jaw. Diagnosis, surgical treatment and physiotherapy.

Course V Faculty Foreign Students Training, Stomatological

Poltava -2020

1. Relevance of the topic:

Inflammatory and degenerative diseases of the TMJ belong to a rather common diseases are very difficult in its clinical course and difficult to treat, the frequency of which increases with age. Therefore, knowledge of the clinic, treatments and prevention of inflammatory and degenerative diseases of the TMJ is currently relevant in the study of this subject.

2. THE SPECIFIC AIMS:

2.1. To define what is arthritis, arthrosis, arthrito-arthrosis of the TMJ. 2.2. To analyze the etiology and pathogenesis arthritis, arthrosis, arthrito-arthrosis of the TMJ. 2.3. To suggest a plan of examination for patient with arthritis, arthrosis, arthrito- arthrosis of the TMJ. 2.4. To classify arthritis, arthrosis, arthrito-arthrosis of TMJ. 2.5. To list the main clinical features of acute TMJ arthritis. 2.6. To list the main clinical features of chronic TMJ arthritis. 2.7. To list the major clinical signs of osteoarthritis and TMJ arthritis. 2.8. To list the major clinical signs of TMJ osteoarthritis. 2.9. To appoint the treatment for patients with arthritis, arthrosis, arthrito-arthrosis of TMJ. 2.10. To analyze the data further diagnostic testing of patients with arthritis, arthrosis , arthritis, arthrosis of the TMJ.

3. BASIC KNOWLEDGE, ABILITIES, SKILLS, WHICH ARE NECESSARY FOR STUDY THEMES (intradisciplinary integration) Names of the previous The received skills disciplines 1. Ethics and deontology To establish psychological contact with the patient 2. Human anatomy. To know the anatomy of TMJ. 3. Normal physiology To know the functionality of the TMJ in the norm 4. Pathomorphology. Describe the morphological and functional changes in TMJ at different pathologies. 5. Propedeutic of internal Apply the methods of inspection of patient with medicine different types of pathology TMJ. 6. Radiology Be able to describe the radiographic images of TMJ 7. Clinical pharmacology To know indications, contraindications, dosage, administration schedule of drugs used in the treatment of pathologies of TMJ.

4. TASKS FOR INDIVIDUAL WORK DURING PREPARATION TO LESSON. 4.1. List of basic terms, parameters, characteristic, which a student must master at preparation to lesson: Term Definition 1. Acute arthritis It is an acute inflammatory disease of the 2. Chronic arthritis It is a chronic inflammatory disease of the joints, with periods of remission and exacerbation. 3. Arthrito- It is a chronic inflammatory-dystrophic diseases of joints arthrosis 4. Arthrosis It is a chronic dystrophic disease of joint

4.2. Theoretical questions for the lesson:

1. Etiology and pathogenesis of arthritis, arthrosis, arthrito-arthrosis of the TMJ. 2. Classification of inflammatory and degenerative diseases of the TMJ. 3. Clinical features and treatment of acute TMJ arthritis. 4. Clinical features and treatment of chronic TMJ arthritis. 5. Clinical features and treatment of TMJ arthrosis-arthritis. 6. Clinical features and treatment of TMJ osteoarthritis. 7. To suggest the treatment regimen of patients with arthritis, arthrosis, arthrito- arthrosis of TMJ. 8. To analyze the data additional diagnostic testing of patients with arthritis, arthrosis, arthrito-arthrosis of the TMJ.

4.3. Practical works (task) which are executed on lesson: 1. To examine patients with inflammatory and degenerative diseases of TMJ. 2. To describe the case history of patients with inflammatory and degenerative diseases of TMJ. 3. To assign examination plan for the patient with inflammatory and degenerative diseases of TMJ. 4. To make a plan of treatment for patients with inflammatory and degenerative diseases of TMJ.

THE CONTENT OF THE TOPIC:

The TMJ is a joint that connects themandible (jaw) to the of the skull. It moves in three different directions. It acts as a hinge, allowing opening and closing of the mouth, and it also moves forward and backward, as in jutting the jaw, known as protrusion and retrusion respectively, and from side to side. The jaw joint is used in many different activities including chewing, talking, and yawning. Because of the frequency in which the jaw joint is used, TMJ syndrome can be extremely disruptive. The TMJ can be found just forward to and below the ears. If you place your fingers in this area and open and close your mouth, you can feel the joint moving. Rubbing in this area can be very painful in people suffering from TMJ syndrome. The TMJ is controlled by three muscles—the temporalis, the masseters, and inside the mouth, the medial andlateral pterygoids. These muscles are also known as the muscles of mastication or chewing muscles. Together they provide the greatest force per surface area of all human movements. Types of Arthritis The TMJ can be involved in both main types of arthritis. Osteoarthritis, the degenerative, ‘wear and tear’ type of arthritis, tends to come on slowly and is more common in later life. Rheumatoid, or inflammatory type arthritis of the TMJ, can develop rapidly, and at any age, in Juvenile, Psoriatic, Infective, Gout and Ankylosing Spondylitis. Pain is usually felt directly over the joints but can be in the ear, teeth, or head. The teeth may not seem to meet together properly and there may be pain on biting, chewing or swallowing. Mouth opening is usually reduced, and the jaw may veer off to one side, or refuse to glide smoothly to each side. It may be difficult to keep the mouth open for dental treatment. Jaw Clicking The jaw may also make clicking or crunching noises on movement. There are two causes of this noise. Bony crepitus where the joint cartilage has degenerated and the bony surfaces are rubbing together is actually quite uncommon. Most people hearing their own jaw click would probably feel that this is exactly what is happening. However this is quite unlikely, especially if the problem is recent. The commonest culprit when a jaw clicks is the disc. What you are usually hearing is the head of the jawbone clicking onto the disc and possibly off it again. The disc may be misshapen or the muscles out of sync, causing it to be in the wrong place. This is similar to the tracking problems we sometimes experience in the . The clicks from the TMJ usually sound much louder and more sinister as they are so close to the ear, and the head is very sensitive. It is also important to bear in mind that mild clicking, in the absence of pain is entirely normal. Without any other symptoms it is not something which requires treatment. Loud, persistent or painful clicking does need to be checked by your dentist, doctor or physiotherapist. Hypermobility People who do need to pay attention to clicking jaw joints are those who may be ‘double jointed’. Patients with Benign Joint Hypermobility Syndrome (BJHS, JHS or Ehlers Danlos Syndrome) have an increased ‘play’ in their soft tissues which allows more than the usual amount of movement in a joint. They are susceptible to damage or injury to the jaw joint because of the excessive movement, and could also be more likely to suffer from inflammatory type arthritis. Normal Jaw Movement When the jaw is open to its widest extent it should accommodate the tips of the index, middle and ring fingers of one hand, held out straight and together. Remember, it’s your own fingers, so whether measuring a child or a large adult, individual variations are taken into account. The lower jaw should be able to slide smoothly forward so it juts forward beyond the top teeth. It should also be able to glide to each side, at least to the outer edge of each central top tooth. Treatment Options Patients with inflammatory conditions, looking for additional pain relief may respond to TENS, using tiny dot electrodes. The area needs to be clean, flat and unblemished to ensure a good seal. The electrodes can be tried in various sites around the cheek area to find the most effective placement. Topical anti-inflammatory creams such as Nurofen or Feldene can be used over the jaw, but patients already on other medications or with pre-existing conditions would need to check with their doctor before using. Capsaicin cream is another pain relieving alternative, which has shown some success in clinical trials. It can be made up by a compounding pharmacist in an oral formula or as a cream, such as Zostrix or Capzasin. Self Help Strategies Jaw problems can be eased or prevented by avoiding the following activities: Nail biting Chewing pens and pencils Sleeping on your tummy Biting off sewing threads or fishing line Constantly chewing gum, Minties, Fantales or crunching ice Grinding the teeth and clenching the jaw Wide biting into huge apples, burgers, or overly chewy crusty bread. Biting into refrigerated chocolate with the front teeth Opening bottles with your teeth (ouch!) Constantly playing with the jaw or clicking it in and out. Rubbing too hard over the bony parts of your jaw- it can make them more tender Performing ‘party tricks’ (like ‘who can put a whole tennis ball in their mouth?’)

Temporomandibular joint pain dysfunction syndrome This is the most common problem in and around the (TMJ) or the jaw joint. Jaw problems affect a person’s ability to speak, eat, chew, swallow and even breathe. Epidemiology Predominantly affects people aged between 20—40 years old. Equal frequency between genders, but five times as many females seek treatment. Affects around 40% of the population at some time in their life. Etiology Idiopathic: It is like to be associated with one of the following: occlusal abnormalities, lack of posterior support, parafunctional clenching habits, nocturnal bruxism, anxiety and depression. (50-70% of patients have experiences stressful life events in the 6 months before onset.) Occasionally the patient may relate the onset of pain to an acute incident of local trauma while eating or yawning. Symptoms Unilateral or bilateral constant dull pain within the TMJ and/ or surrounding muscles around the ear. Pain on chewing, yawning or talking Some people may not have pain but still have problems using their jaws. If bilateral, one side usually worse , limited jaw movements Occasionally the TMJ may lock open or closed Sounds—clicking, crunching or grating (crepitus) are often described Headaches, facial pain and neck related aches Cyclic pain which usually resolves, but may recur A bite that is uncomfortable or feels “off”. Swelling on the side of the face, neck, , and back pain. Ringing in the ear, decreasing hearing, dizziness, and vision problems. Signs Joint clicking—generated by displacement of the articular disc from head of condyle and then ‘popping’ back into correct position Pain may be elicited on palpation of the TMJ and masticatory muscles. The muscles may be hypertrophic due to parafunction Mandibular movement may be limited and deviation may occur on the opening or closing cycle Parafunction habits in up to 50% of cases Bruxism can be suggested by scalloping of the lateral borders of the tongue, ridging of the buccal mucosa, tooth wear, restoration wear, fracture, dentine exposure and sensitivity Investigations Organic causes of pain or limited movement should be ruled out by investigation. Radiography is not recommended for diagnosis unless there is a history of trauma, significant limitation of movement, sensory or motor alteration, or a possibility of organic joint or other disease. Trigeminal neuralgia can be occasionally triggered by movement of the jaw and should be suspected in older patients, particularly where pain is severe and paroxysmal. Management Many people with TMJ problems get better without treatment. Often the problem goes away on its own in several weeks to months. Most cases are self-limiting; therefore treatment should be conservative and reversible i.e., without causing any permanent changes to jaw or teeth. Patient information is an important aspect - Reassure and Explain Habit management – Rest, avoidance of trauma and gentle jaw stretching and relaxation exercises. Occlusal appliances (biteplate, nightguard) Analgesia (NSAID’s), heat and massage, TENS Muscle relaxants (Clonazepam or Baclofen) can give relief Psychological Rx: hypnosis, behavior modification, group therapy Occasionally anxiolytic medications (diazepam 5mg 1 hour before sleep, then 2mg twice daily, for up to 10 days maximum) can be useful. Antidepressant medication (tricyclics) where indicated. Occlusal adjustment of the natural teeth by selective grinding is irreversible and not recommended. Orthodontics is an option for repositioning of teeth. Surgery may be required for the very small number of non-responders, especially those with obvious intra-articular pathology (osteoarthritis)

TMJ Ankylosis Ankylosis is the stiffening (immobility) or fixation (fusion) of the joint. Chronic, painless limitation of the movements of the joint occurs. Intra-articular (true) ankylosis must be distinguished from extra-articular (false) ankylosis. False ankylosis may be caused by enlargement of the coronoid process, depressed fracture of the zygomatic arch, scarring from surgery, irradiation, infection, etc. True ankylosis of the mandible is one of the most disturbing articular pathosis of TMJ, causing many psychological and physical disturbances. When the pathosis affects both the joints it completely inhibits the movements of the mandible, making chewing, swallowing and speech very difficult. The facial development is impaired resulting in retarded growth of the mandible. Since the condyle of the mandible is the growth center (area of bone growth) for the mandible, any disturbance in this region provokes a change in the development of the mandible. True bilateral congenital ankylosis of the TMJ leads to micrognathia or “bird face”. If ankylosis affects only one side, it produces a lateral deviation of the jaw to the non-affected side, due to the fact that this side continues its growth normally. Therefore the deformity becomes more evident on the normal side, with deficiency on the ankylosed side, causing a facial asymmetry. Causes of TMJ Ankylosis  Trauma to the joint during an accident, fall etc  Trauma during birth, forceps delivery etc  Congenital or birth defect  Disease or infection in the joint, ear infection etc  Enlargement of the coronoid process  Depressed fracture of the zygomatic arch, condylar neck fracture etc  Surgery to or around the joint  Rheumatoid arthritis  Ankylotic conditions such as ankylosing spondylitis may also be inherited.  Destruction of the joint cartilage Since the condyle of the mandible is an area of bone growth, any inflammatory process in this region, no matter how simple it may be, always provokes a change in the development of the mandible. In most cases of true ankylosis x-rays of the TMJ show loss of normal bony architecture. Ankylosis of Temporomandibular joint may result in:  Restricted jaw movements  Inadequate masticatory (chewing) function  Restricted mouth opening  Inhibited facial and physical growth  Impaired speech  Reduced growth of mandible resulting in “Bird Face”  Facial asymmetry if only one side is affected  Difficulty in breathing and swallowing  Snoring and difficulty in sleeping on lying down  Insufficient access for dental care resulting in multiple decayed teeth  Misaligned teeth because of lack of space for the eruption of the normal component of teeth  Other emotional, social and psychological disturbances. Treatments for TMJ ankylosis Over the past few decades numerous treatment methods have been designed and developed by various surgeons for the correction of TMJ ankylosis. 1. Excision of ankylosis (gap arthroplasty) 2. Arthroplasty with or without autogenous, alloplastic or allogenic replacement 3. Condylectomy if the ankylosis is intra-articular or an osteotomy of a part of the ramus if the coronoid process and zygomatic arch are also affected. 4. Total condylectomy and joint replacement (autogenous, allogenic, alloplastic) 5. Myotomy 6. Coronoidectomy or coronoidotomy: This is the excision of the coronoid process of the mandible to release the temporalis muscle. Therapeutic treatment (biphosphonates, NSAIDS) and physiotherapy to discourage reankylosis of the joint is very important after any surgical corrections. Patient compliance to the postoperative is essential to success of any surgical treatment. Jaw-opening exercises must be performed for months to years to maintain the normal mouth opening. Inter-positioning of the TMJ with temporal fascia or cartilage maybe done to prevent reankylosis of the joint. In cases of bilateral true ankylosis, the treatment is more complex. Facial deformity and asymmetry can be corrected by bone grafts, distraction ontogenesis, orthognathic surgery --- saggital split osteotomy, genioplasty, or Extended-sliding genioplasty (a technique developed and propagated by Dr Varghese Mani).

DISLOCATION OF THE MANDIBLE There can be a dislocation of jaw if a person opens their mouth too wide, particularly when a person attempts to open the jaw widely in an effort to stretch the facial muscles i.e. to relieve tense facial muscles as the wisdom teeth develop and emerge. Dislocation can occur following a series of events if the jaw locks wide open and is unable to close by using the jaw muscles (unassisted) and without excessive force;. As an immediate result of the dislocation, chronic pain can be experienced on both sides of the jaw, combined with an extreme headache and inability to concentrate. Depending on the severity of the jaw's dislocation, pain relief using paracetamol can assist to alleviate the initial chronic pain, however the effects of long-term use of paracetamol can decline as the condition deteriorates with continued use of the jaw through the day i.e. talking, eating, smoking, drinking, etc.  Most dislocations occur spontaneously on opening the mouth widely for yawn, dental work, during  Trauma may also produce dislocation  Trauma involving a downward force on partially opened jaw  Those with previous dislocations are at much greater risk for repeat dislocation  Shallow mandibular fossa may predispose to dislocation  Connective tissue diseases like Marfan’s or Ehlers-Danlos may have increased risk  May eventually result in osteoarthritis in TM joint Predisposing Factors for Jaw Dislocation:

 Most dislocations occur spontaneously on opening the mouth widely for yawn, dental work, during seizure  Trauma may also produce dislocation  Trauma involving a downward force on partially opened jaw  Those with previous dislocations are at much greater risk for repeat dislocation  Shallow mandibular fossa may predispose to dislocation  Connective tissue diseases like Marfan’s may have increased risk  May eventually result in osteoarthritis in TM joint

Clinical Findings:

 Dislocations of the lower jaw (mandible) tend to be  The presence of a jaw fracture increases the pain  Patients are unable to close mouth completely  Difficulty speaking and, possibly, swallowing  Dislocations may be one-sided or both (unilateral or bilateral)  The lower jaw comes forward (prognathic) appearance to jaw when both are dislocated Imaging Findings:

 Conventional X-ray is usually diagnostic  Mandibular condyle lies forward (anterior) to the articulate eminence on one or both sides

The symptoms can be numerous depending on the severity of the dislocation injury and how long the person is inflicted with the injury. The immediate symptom can be a loud crunch noise occurring right up against the ear drum. This is instantly followed by excruciating pain, particularly in the side where the dislocation occurred. Short-term symptoms can range from mild to chronic headaches, muscle tension or pain in the face, jaw and neck. Long-term symptoms can result in sleep deprivation, tiredness/lethargy, frustration, bursts of anger or short fuse, difficulty performing everyday tasks, depression, social issues relating to difficulty talking, hearing sensitivity (particularly to high pitched sounds), tinnitus and pain when seated associated with posture while at a computer and reading books from general pressure on the jaw and facial muscles when tilting head down or up. .

6. MATERIALS FOR SELF-CONTROL: A. Questions for self-control: 1. Medical kart of patients with TMJ disorders. 2. Plans of examination of the patient with TMJ disorders. 3. Treatment regimen for patients with TMJ disorders.

B. Tasks for self-control: 1. Patient N., 35 years old with a diagnosis of chronic arthritis of left TMJ complains on limitation of mouth opening. When the limitation of mouth opening during exacerbation of chronic arthritis is possible? Answer: During the exacerbations of disease. 2. The patient P., 39 years old has diagnosis rheumatoid arthritis of right and left TMJ. What are common symptoms of rheumatoid arthritis TMJ? Answer: Affection of both TMJ.

C. Materials for test control. Test tasks with the single right answer (a=II): 1. For pathogenetic features of TMJ arthrosis is: A. Primary and secondary. B. Sclerosing and deforming. C. Serous and purulent. D. Acute and chronic. E. Hypertrophic and atrophic. (Correct answer: A) 2. In the pathogenesis of primary osteoarthritis is characterized by: A. Development of degenerative process in healthy articular cartilage. B. Development of degenerative process changed as a result of articular cartilage injury. C. The development process degenerative healthy articular head. D. Development of degenerative process in articular fossa. E. Development of degenerative process in the joint as a result of somatic disorders in general. (Correct answer: A) 3. How many radiographic stages of secondary deforming osteoarthritis are? A. 4 stages. B. 3 stages. C. 5 stages. D. 6 stages. E. On stage no difference. (Correct answer: A)

D. Educational tasks of 3th levels (atypical tasks): 1. Patient W. 46 years, with diagnosis acute arthritis of left TMJ was hospitalizated in clinic of dental surgery. By etiology of TMJ arthritis can be: (Answer: The exchange-degenerative, specific and non-specific, post-traumatic) 2. Patient G., 34 years, appeared to surgeon dentist with complaints of pain in the TMJ, the patient was carried out by X-rays of the joint by Schiller. What are the radiographic changes in the TMJ at his disease: (Answer: Absence of joint space, narrowing of the joint space is observed rarely, the initial repair events, limits the mandible fossa and articular process smoothed out, approaching a straight line). 3. Patient P., 23 years old, with diagnosis acute arthritis of left TMJ. Clinical signs of acute TMJ arthritis are: (Answer: Constant pain that decreases in the rest of the lower jaw, swelling and infiltration of the soft tissues in front of tragus of ear, serous or purulent exudate in the joint cavity).

LITERATURE. Basic literature: 1. Oral and maxillofacial surgery: textbook / Ed. by prof. V. Malanchuk / part one. – Vinnytsia: Nova Knyha Publishers, 2011. – 424 p. 2. Avetikov D.S. Using of modern methods of diagnostics in the practice of oral surgery: Text-book / Avetikov D.S, Skikevych M.G., Lokes K.P., Bojchenko O.M.-Poltava-2018 -122p. 3. S.I. Danylchenko Operative surgery and topographical anatomy: Text-book/ S.I. Danylchenko, E.N. Pronina, D.S.Avetikov .- Poltava-2011-239p. 4. Tkachenko P.I. Propaedeutics of surgical stomatology and inflammatory diseases of maxillofacial region / P.I. Tkachenko, A.I. Pan’kevich, K.Yu. Rezvina. – Poltava. – ASMI, 2001. – 283 p.

Additional:

1. Peterson’s Principle of oral and maxillofacial surgery. 3rd Edition / M. Miloro, G.E. Ghali, P.E. Larsen, P.D. Waite. – Hamilton London, BC Decker Inc, 2012. – 1664 p. 2. Textbook of general and oral surgery / D. Wray, D. Stenhouse, D. Lee, A. Clark. – Edinburg, London, New York, Philadelphia, St Louis, Toronto, Churchill Livingstone, 2003. – 322 p. 3. Coulthard P. Master dentistry / P. Coulthard, K. Horner PH. Sloan, E. Theaker. – Edinburg, London, New York, Philadelphia, St Louis, Toronto, Churchill Livingstone, 2003. – 267 p. 4. Oral and Maxillofacial Surgery / J. Pedlar, J. Frame. – Edinburg, London, New York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 2003. – 325 p. 5. Principle of oral and maxillofacial surgery / Ed. by U.J. Moore. – Blackwell Science, 2001. – 276 p.

Useful Websites:

Medicsdirect

National Center for Emergency Medicine Informatics

Emedicine.com

Learning Radiology.com

Patient UK

The Mayo Clinic

Methodological recommendations were prepared by Associate Professor Skikevych M.G.