Diseases of the temporomandibular joints, facial pain and neuromuscular diseases. Markéta Hermanová Components of temporomandibular joint (TMJ) nMandibular condyle (3 zones distinguished in the articular surface during development) -Articular zone -Proliferative or cellular zone -Hypertrophic zone nArticular fossa of the temporal bone nArticular disc (fibrocartilage) -Anterior band (pterygoid muscle attached to medial part) -Intermediate zone -Posterior band -Retrodiscal tissues Developmental disorder nHypoplasia or underdevelopment of the condyle -Congenital -Acquired (trauma, radiation, infection) nHyperplasia of the mandilular condyle (unknow etiology) nAplasia of the condyle -Unilateral -Bilateral - Inflammatory disorders nTraumatic arthritis or haemarthrosis n(intracondylar fractures, dislocation, hyperextension sprains – resolution, scar formation, ankylosis) nInfective arthritis (Staphylococcus aureus) -Direct spread (middle ear, form surrounding cellulitis) -Haematogenous spread (distant focus) -Facial trauma -Involvement of TMJ in wide spread of gonococcal or viral arthritis nClinically pain, trismus, deviation on opening, signs of acute infection. nRheumatoid arthritis (RA) -Non organ specific autoimmune disease with articular and diverse extra-articular manifestation -F>M; usually smaller joints affected; ofted ass. with Sjögren sy -20-70 % at some time TMJ involvement -Limitation of opening, stiffness, crepitus, pain, tenderness -Lymphoplasmocellular synovitis→proliferation of synovial tissue→formation of vascular pannus→erosion and resorption of adjacent bone→fibrous a nd complete ankylosis -Rheumatoid factor: IgM-class autoantibody against chemical groups on IgG (in 85 % patients) Immune reaction and morphology of RA RA imuno RA pannus Osteoarthrosis (osteoarthritis) nDegenerative rather than inflammatory disease nIncreasing incidence after 50 years nDegenerative changes, denudation, and eburnation of condyle nLimitation of opening, crepitus, pain, deviation on opening nRelated to untreated myofascial pain-dysfunction sy, loss of molar support nFibrillation, fragmentation and loss of the articular surface; denudation of hte underlying bone, reactive changes in the exposed subarticular bone; osteophytes; perforation of articular disc nRadiography: loss on the articular surface of the condyle, flattening and reduction in the total bony size of the condyle, reduction of the joint space, osteophytes, their fractures-loose bodies Myofascial pain-dysfnuction syndrome nMasticatory muscle spasm nSymptoms: pain ass. with joint or its musculature, clicking of the joint, limitation of jaw movement nTenderness of masticatory muscles nF>M nass. with unilatral tooth loss, dental irregularities, emotional stress (bruxism, nocturnal tooth grinding habits) n n - Disc displacement nAbnormal positional relationship between articular disc, head of the condyle, and the articular fossa of the temporal bone n25-65 % of elderly patients nPrevalent in myofascial pain-dysfunction sy and in osteoarthritis nInitially adaptive, later remodelling of the disc (shape, proportions, fibrosis, hyalinisation in retrodiscal tissue, haemorrhage, myxomatous changes, cartilage formation, perforation of the posterior attachement,…..) Loose bodies nRadiopaque bodies lying in the joint space nDiscomfort, crepitus, limitation of opening nCauses: intracapsular fractures, fractured osteophytes, synovial osteochondromatosis (multiple nodules of metaplastic cartilage – unknown etiology) n n n n n Age changes in the jaws and TMJ nOsteoporosis nAtrophy of alveolar bone, loss of teeth nOsteoarthrosis nDisc displacement n Neoplasms nExtremely rare nBenign chondromas and osteomas nMalignant sarcomas (bone, soft and synovial tissues) Trismus – limitation of movement in the temporomandibular joints - causes nIntra-articular -Traumatic arthritis -Infective arthritis -Rheumatoid arthritis -Dislocation -Intracapsular fracture -Fibrous or bone ankylosis folllowing trauma or infection n nExtra-articular -Adjacent infection, inflammation or abscess (e.g. mumps, pericoronitis, submasseteric abscess,…) -Extracapsular fractures (mandible, zygoma,…) -Overgrowth (neoplasia) of the coronoid process -Fibrosis from burns or irradiation -Haematoma/fibrosis of medial pterygoid (e.g. after inferior dental block) -Myofascial pain-dysfunction syndrome -Tetanus -Tetany -Drug-associated dyskinesia and psychotic disturbances Bell´s palsy (idiopathic 7th nerve paralysis: idiopathic facial paralysis) nTriggering events: -Acute otitis media -Atmospheric pressure change (diving, flying) -Exposure to cold -Ischemia of the nerve near the stylomastoid foramen -Local and systemic infection (viral (herpetic), bacterial, fungal) -Melkersson-Rosenthal sy (cheilitis granulomatos, facial paralysis and fissured tongue) -Multiple sclerosis -Pregnancy (3rd trimestr, early eclampsia) -Lyme disease -sarcoidosis n n Other facial and cervical neuralgias nTrigeminal neuralgia: the extreme, paroxysmal and lancinating pain, usually initiated by light touch to a trigger point nGlossopharyngeal neuralgia nMigrainous neuralgia nOccipital neuralgia nParatrigeminal neuralgia nPostherpetic facial neuralgia nTympanic plexus neuralgia nSphenopalatine ganglion neuralgia nSuperior laryngeal neuralgia nNeuralgia induced cavitational necrosis (3rd molar) Motor neuron disease – progressive degeneration and death of the motor neurons nDysphagia nFasciculation (small, synchroneous, subcutaneous muscle contraction) nBulbar paralysis Spinal muscular atrophy nAR nSMN1 (survival motor neuron gene) – 95% SMA n1/6000-10000 n2-3% carriers n2nd most common after cystic fibrosis (mucoviscidosis) 13-b07b 19-f04 Amyotrophic lateral sclerosis n90 % sporadic ALS nF:M – 1,7:1 nolder people, survival 3-4 years, first symptoms in 56-63 years, upper extremities preferentially affected, bulbar symtomatology n10 % hereditary ALS (4th decade, juvenile forms, F:M – 1:1) Myastenia gravis nAutoimmune disease nAntibodies against AChR nAbnormal progressive fatigability of skeletal muscle nAss. with thymoma or thymus hyperplasia nClinical symptoms: -An inability to focus the eyes (extraocular muscular paresis) -Drooping eyelids (ptosis) -Double vision (diplopia) -Difficulty in chewing -Difficulty of swallowing (dysphagia) -Slurring of words (dysarthria) - Thank you for your attention …