Nomenclature and classification of temporomandibular joint disorders

Currently, there are basically two approaches to classification, one based on structural and one on positional changes occurring within the joint. Despite the increase in knowledge of pathologic changes occurring within the temporomandibular joint (TMJ), the disc still seems to be a central issue in nomenclature and classifications of TMJ disorders. Basic pathologies of the TMJ involve inflammation and degeneration in arthritic disorders (irrespective of the presence or position of the disc) and structural aberrations in growth disorders. Some internal derangements may occur independent of underlying pathology, e.g. because of a traumatic event. In this position paper, a classification of TMJ disorders is proposed based on basic structural changes occurring in the joint.     

颞下颌关节疾病的外科手术治疗

目的 :颞下颌关节疾病的治疗包括保守治疗和外科手术治疗 ,本研究目的是探讨颞下颌关节疾病外科手术治疗的适应证以及手术方法。方法 :对 1988年至 2 0 0 0年共收治的 76 5例颞下颌关节疾病患者进行回顾性研究。其中颞下颌关节紊乱病患者共 4 18例 ,颞下颌关节外伤 15 9例 ,颞下颌关节强直 131例 ,髁状突肥大 38例 ,颞下颌关节肿瘤 18例 ,颞下颌关节感染 1例 ,其中 6 37例进行了外科手术治疗。结果 :颞下颌关节紊乱病患中 2 18例行颞下颌关节内窥镜术 ,2 1例行颞下颌关节盘复位术 ,91例行颞下颌关节盘修补术 ,11例行陈旧性关节脱位开放复位术 ;131例行颞下颌关节成形术 ;10 9例行髁状突骨折开放复位术 ;38例行髁状突截骨术和正颌手术 ;18例行颞下颌关节肿瘤切除术。结论 :颞下颌关节紊乱病、损伤、关节强直、肿瘤、畸形以及其他关节疾病的手术适应证范围在不断地扩大 ,颞下颌关节外科的手术方法也在不断地改良。颞下颌关节外科手术治疗正向着微创和恢复关节功能的方向发展     

Temporomandibular joint direct sagittal computed tomography: evaluation of image-processing modalities

Computed tomography (CT) is a useful method for examination of the temporomandibular joint because it allows visualization of the articular disk. In computed tomography many factors play an important role in image reconstruction and image processing. The use of image-processing modalities (such as window variation and level detection) has far-reaching consequences on the display and interpretation of the direct sagittal CT image of the temporomandibular joint (TMJ). In this study, the most important image reconstruction and processing factors were studied for use in the diagnosis of internal derangements and other disorders of the TMJ. Optimal values for the setting of the CT system for the different techniques are discussed.     

正常颞下颌关节与人工关节假体髁突的运动比较

颞下颌关节髁突的运动对于关节疾病的诊断和治疗有重要意义,髁突运动的测量方法众多,可分为有创性和无创性两大类。文章对有关正常颞下颌关节和人工关节假体髁突运动测量方面的文献进行综述,旨在为自主人工关节假体的设计提供参考。     

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?? The kinematic of condyle in the temporomandibular joint ??TMJ?? is important for the diagnosis and treatment for TMJ disorders. There are many methods for the condylar kinematic measurement??including invasive and non-invasive ones. This article reviewed the literature on kinematic measurement of natual condyle and TMJ prosthesis??in order to provide reference for the home-made TMJ prosthese design.     

The role of facial trauma as a possible etiologic factor in temporomandibular joint disorder.

PURPOSE: Facial trauma has been suggested as a possible etiologic factor of temporomandibular joint disorder. However, there is little information on the role of macrotrauma. The main purpose of this study was to validate facial trauma as a potential etiologic factor for temporomandibular joint (TMJ) disorder. Multidirectional approaches were applied for the evaluation of the changes of TMJ after TMJ macrotrauma. PATIENTS AND METHODS: Analysis of TMJ status including arthroscopic examination, histomorphologic examination, and synovial fluid biochemical analysis were performed on the patients with mandibular fractures. Additionally, the efficacy of arthrocentesis for the patients of mandibular fracture was evaluated from the functional point of view. RESULTS: In arthroscopic examinations, evidence of synovitis with variable degrees was found. The representative findings are fibrillation and ecchymosis. On histomorphologic examination, bloody smear, degenerated cells and cartilage, inflammatory cells, and crystal were observed. In biochemical analysis, considerable amounts of prostaglandin E(2) and leukotriene B(4) were detected in the synovial fluid of the patients. CONCLUSION: The inflammatory and degenerative changes of TMJ can develop after facial trauma. Trauma can be a possible etiologic factor in cartilage degeneration, and biochemical and intra-articular pathology. Clinicians should recognize the etiologic importance of macrotrauma, and long-term evaluation of the TMJ as well as adequate treatment is required for patients with facial trauma.     

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颞下颌关节(TMJ)是人体全身关节中解剖结构与功能最为复杂、精细的关节之一,而颞下颌关节功能紊乱病(TMD)又是人体好发的疾病之一且病因尚不明确。因此,在临床检查及治疗中及时观察TMJ形态、位置尤其重要。临床常用的X线片不能清晰准确地显示TMJ骨性结构的形态及变化。多层螺旋CT是近几年发展起来的影像技术,以其独特的技术,如骨最大密度投影法、表面遮盖法、多层面重建术、容积成像等,对TMJ进行三维显影,使TMJ形态及其骨性结构更为准确清晰,但其对关节盘的显影有一定的局限性。本文对多层螺旋CT在TMJ中的应用做一综述,以期对临床有所帮助。     

The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders

Because the concept of whiplash as a causative factor for temporomandibular disorders (TMD) is highly controversial, we decided to do a retrospective analysis of patients treated in our office who had sustained whiplash injuries and were treated for cervical and temporomandibular disorders. The records of 300 patients with TMD preceded by a motor vehicle accident were examined retrospectively. The most common presenting symptoms, in order, were: jaw pain, neck pain, post-traumatic headache, jaw fatigue, and severe temporomandibular joint (TMJ) clicking. The most common TMD diagnoses were: masseter trigger points, closing jaw muscle hyperactivity, TMJ synovitis, opening jaw muscle hyperactivity, and advanced TMJ disk derangement. Based primarily on the physical examination, we concluded that the TMJ and surrounding musculature should be examined similarly to other joints, with no preconceived notion that TMD pathology after whiplash is unlikely.     

Occlusal stabilization appliance: evaluation of its efficacy in the treatment of temporomandibular disorders

Occlusal stabilization appliances or splints are the most widely employed method for treatment of temporomandibular disorders (TMD). Magnetic Resonance Imaging (MRI) is the most indicated imaging modality to evaluate the components of the temporomandibular joint (TMJ). Forty patients with signs and symptoms of temporomandibular disorders were treated with splints for a mean period of 12 months, comprising regular semimonthly follow-ups. After stabilization of the clinical status, occlusal adjustments and MRI evaluation were performed. It was concluded that the success of this kind of treatment are related to the total (70%) or partial improvement (22.5%) of painful symptomatology and to the functional reestablishment of the craniomandibular complex. The MRI allowed evaluation and also the conclusion that the splints provide conditions for the organism to develop means to resist to the temporomandibular disorders by means of elimination of several etiologic factors. Moreover, after treatment the patients are able to cope with disc displacements with larger or smaller tolerance.     

Role of panoramic radiographis in differential diagnosis of patients with temporomandibular dysfunction

We reviewed the records for 4 patients with temporomandibular disorders (TMD), in all of whom temporomandibular joint (TMJ) arthrosis was initially suspected because of the clinical symptoms such as limited mouth opening and pain at the TMJ region. However, careful observation of the panoramic radiographs disclosed abnormalities other than TMJ arthrosis, including, obliteration of the posterior maxillary sinus wall (caused by squamous cell carcinoma of the maxillary sinus), resorption around the condylar neck (caused by hemangioma), and radiopaque foci at the anterior area of the right TMJ (synovial chondromatosis). Some of these abnormalities were not observed on the oblique lateral transcranial projection and the transorbital projection. Although panoramic imaging provides rather blurred images of the TMJ region it produces a broad image of the maxillofacial region which is helpful in the detection of neoplasms and other disorders. Its careful interpretation should be emphasized especially in the differential diagnosis of TMD.     

Temporomandibular joint devices: Treatment factors and outcomes

TMJ devices have been used for many years in reconstruction of the temporomandibular joint (TMJ). The most common endosseous implant currently used in TMJ reconstruction is a mini-anchor that is placed in the posterior head of the condyle to support artificial ligaments to stabilize the articular disk in the proper position. A 2-year follow-up study shows a success rate of 90% in reference to incisal opening, jaw and occlusal stability, and significant reduction in presurgical pain level. Some materials that have been used in TMJ reconstruction, including Proplast-Teflon (PT) and Silastic devices, have caused devastating problems for patients. These materials, (particularly the PT) can cause severe foreign-body giant-cell reaction, severe bone and soft-tissue destruction, and migration of particles to other body areas, and may initiate or exacerbate connective tissue and autoimmune disease problems. Christensen joint prosthesis has been reported to have very good success in TMJ reconstruction. The most thoroughly studied TMJ total joint device is the Techmedica custom-made total joint prosthesis, with a 5-year follow-up study on 31 patients and 52 reconstructed joints. All patients have functioning prostheses with good jaw and occlusal stability and an average pain reduction of 4.4 points on a 0-to-10 visual analog pain scale. However, this device currently is unavailable. In complex cases requiring multiple TMJ operations, particularly those with previously failed alloplast, a custom-made total joint prosthesis, using materials with proven safety and efficacy in orthopedic joint reconstruction, may be the only option available to improve predictably the quality of life of these patients.     

颞下颌关节疾病的外科治疗

颞下颌关节疾病(temporomandibular joint disease,TMD)包括颞下颌关节紊乱病、颞下颌关节损伤、颞下颌关节脱位、颞下颌关节强直、先天性或后天性畸形、炎性疾病以及肿瘤等,治疗方法有保守治疗和外科治疗。基础研究有助于了解颞下颌关节疾病的致病机理,并为颞下颌关节疾病的治疗提供理论依据。虽然颞下颌关节疾病的治疗多年来存在争议,但随着对颞下颌关节疾病了解的加深,以及影像学的发展、关节镜和手术方法的改进,颞下颌关节疾病的外科治疗有了明显进步。本文对颞下颌关节紊乱病、颞下颌关节脱位、髁突骨折、颞下颌关节强直、先天性或后天性畸形以及肿瘤等颞下颌关节疾病的外科治疗现况及进展进行了阐述。     

全身(远处)感染致颞下颌关节强直:1例报告及文献复习

颞下颌关节强直可由创伤、感染、退行性变及间隙缺损导致。其中以局部感染多见,而全身感染则罕见。本文报道1例因全身远处感染导致双侧颞下颌关节强直的患者,该35岁女性患者因开口困难近20年就诊,并于20年前出现包括颞下颌关节区的全身多处脓肿,CT显示髁突与颞骨融合。采用双侧颞下颌关节截除术及人工关节置换术治疗,术后3个月开口度达2.5 cm,患者获得了满意的进食及语言功能。     

Borrelia burgdorferi--a potentially aetiological factor in TMJ disorders? Preliminary report.

INTRODUCTION: The available literature does not report on infectious factors potentially triggering intra-articular pathology or dysfunction manifest as temporomandibular (TMJ) disorders. AIM OF THE STUDY: To establish the presence of Borrelia burgdorferi spirochaetes in the histopathological material obtained from the intra-articular space by arthroscopy from patients with advanced TMJ disorders. SUBJECTS AND METHODS: The histopathological material was obtained intra-articularly from 31 patients by means of arthroscopy; apart from routine H+E staining, the material was additionally examined for the presence of micro-organisms (spirochaetes) by the Warthin-Starry method. RESULTS: Seven out of 31 patients presenting with manifesting TMJ dysfunction had spirochaetes detected in the histopathological material; their shape and size resembling B. burgdorferi bacteria. CONCLUSION: This paper is the first to indicate that in borreliosis the infective agent may localize itself to the temporomandibular joint. This observation cannot be ignored when analyzing the pathogenesis of TMJ degeneration especially that tick-borne infections with spirochaetes are definitely more common than it is generally believed.     

Rheumatoid arthritis of TMJ--a diagnostic dilemma?

Rheumatoid arthritis is a chronic disease affecting the musculo-skeletal connective tissue of the body with a strong predilection for the joints. The temporomandibular joint (TMJ) is commonly affected with rheumatoid arthritis in adults and children, but it is usually among the last joints to be affected. A case report is presented of a patient undergoing orthodontic treatment who developed unilateral condylar changes and whose serum was also positive for rheumatoid factor. The involvement of TMJ in several systemic disorders is a well established fact. When such disorders manifest in an atypical manner, it poses a diagnostic dilemma. This article aims to discuss various disorders causing condylar erosions.     

Non-invasive measurement of the deep temperature of the temporomandibular joint region

This study was carried out to non-invasively measure the deep temperature of the temporomandibular joint (TMJ) region at rest and after 100 opening and closing movements of the mandible. Using a transcutaneous probe, we performed deep thermometry by the zero-heat-flow method. A RAM-Pack recording system was employed, and the data were processed by and stored in a microcomputer. In 20 normal male subjects, no differences were observed in the deep temperature of the right and left TMJ regions at rest and after exercise. However, in patients with temporomandibular disorders, the deep temperature of the symptomatic joint was higher than that of the asymptomatic joint. The difference, however, gradually decreased to normal with occlusal splint therapy. Thus, it is clear that the deep temperature of the TMJ region provides useful information about inflammation of the TMJ.     

Early diagnosis of osteoarthrosis of the temporomandibular joint: correlation between arthroscopic diagnosis and keratan sulfate levels in the synovial fluid

The role of osteoarthrosis (OA) and proteoglycan degradation in the pathogenesis of temporomandibular joint (TMJ) disorders has not been well established. The orthopaedic literature has demonstrated that proteoglycan degradation plays a significant role in the pathology of many joints. The purpose of this investigation was to determine if levels of immunoreactive keratan sulfate (an important component of cartilage proteoglycans) present in synovial fluid aspirates from TMJs correlated with arthroscopically demonstrated OA. Temporomandibular joint arthroscopy was performed on 25 joints in 20 patients and synovial fluid aspirates were obtained just prior to the insertion of arthroscopic cannulas. The results showed that synovial fluid aspirates from joints that arthroscopically demonstrated OA had significantly higher levels of keratan sulfate than synovial fluid aspirates from those joints that showed no evidence of OA (NON-OA). This study gives support to the theory that the pathogenesis of OA of the TMJ is similar to that of chondromalacia of other synovial joints. The combination of TMJ arthroscopy and synovial fluid analysis is an important model that can be used for investigation of the pathogenesis of TMJ disorders.     

Impalement of an unusual foreign body on the temporomandibular joint causing severe trismus

A penetrating injury by a foreign body is comparatively common in the oral and maxillofacial region. On the other hand, injury to the temporomandibular joint (TMJ) by a foreign object is very rare. The TMJ is an anatomically narrow space surrounded by hard bony processes. An unusual case of trauma with severe trismus caused by a foreign body that impaled the TMJ is reported. A 55‐year‐old man presented with a 5 × 1‐cm laceration to the right cheek caused by a flying object propelled during the use of a lawn mower. The edge of the foreign body had a metallic wire, which became imbedded in the wound. His jaw opening was severely limited. Computed tomography revealed that the foreign body was 3 mm in diameter and was impaled on the articular capsule. The object was successfully removed, and the wound and interior of the TMJ were irrigated. Rehabilitation of mouth opening was started on postoperative day 3. On day 9, mouth opening had improved to 35 mm, and he was discharged. After 1 year, mouth opening was 45 mm with no sign of any TMJ disorders.     

Physiotherapy as an adjuvant therapy for treatment of TMJ disorders

Physiotherapy has long been used to cure joint and muscle diseases. It has also been used to treat various diseases without inflicting mental trauma or the pain of surgery. This adjunctive therapeutic modality is widely used for patients with orofacial disorders, especially in the prevention or treatment of temporomandibular joint (TMJ) disorder, hypomobility, or ankylosis. Physiotherapy has a particular importance in the treatment of TMJ disorders such as myofascial pain and internal derangement. This review article highlights the importance of physiotherapy as an emerging adjuvant therapy in the treatment of TMJ disorders.