CLINICAL SYMPTOMS

Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis,

treatment, complications, prevention. arthritis, arthrosis temporomandibular

joint (TMJ): classification, clinical course, diagnosis, treatment,

complications and prevention. TMJ syndrome of pain disfunction. Surgical

TMJ arthroscopy.

CLINICAL SYMPTOMS

ACUTE SINUSITIS < 3 weeks

SUBACUTE SINUSITIS 3 weeks-3 months

CHRONIC SINUSITIS > 3 months

SYMPTOMSBloked nose

Headache

Fever

Yellow or green-coloured mucus from the nose

Swelling of the face

Aching teeth in the upper jaw

Loss of the senses of smell and taste

Persistent cough

Generally feeling unwell

MAXILLARY SINUSITIS

FROM DENTAL ORIGIN

1.Periapical abscess

2.Periodontal diseases

3.Infected dental cyst

4.Dental material in antrum

5.Oroantral communication

1.Periapical abscessAcute sinusitis

Anaerobic organisms

2.Periodontal diseases

Lane & O’Neal

Chronic sinusitis

5 years irrigation + antibiotics

examination communication with the maxillary

sinus via a periodontal pocket

3.Infected dental cystPeriapical cyst

Most common of all cysts of the oral region

Epithelium rest of Malassez

The cyst enlarges in to the maxillary sinus

4.Dental material in antrum

1.Displacement of root

extraction

third molar > second molar > canine

Pa or occlusal film loss of lamina dura

2.Implant

3.Root canal overfilling

CASE REPORTS

CASE REPORTS

1.Antral puncture and sinus irrigation

2.Intranasal antrostomy or Nasoantral Window

3.Caldwell – luc operation

3.Caldwell – luc operation

Mandibular condyle (head)Glenoid fossaArticular

tubercle (eminence)

Lateral pterygoid muscle raphe Lower head of lateral pterygoid muscle

Anterior band of articular disc

Mandibular condyle (head)

Posterior band of articular disc

Posterior disc attachment

Mandibular condyle (head)

Articular disc

MRI and autopsy sections: upper row oblique sagittal MRI, asymptomatic volunteer: left lateral, middle medial, rightopened mouth

lateral sectionscentral sections open-mouth

Partial anterior disc displacement at baseline

Complete anterior disc displacement

Open-mouth MRI

medial section Autopsy

Lateral disc displacement and normal bone

Medial disc displacement

Oblique coronal MRIcoronal MRI

Posterior disc displacement

Definition Non-inflammatory focal degenerative disorder

of synovial joints, primarily affecting articular cartilage and sub-condylar bone; initiated by deterioration of articular soft-tissue cover and exposure of bone.

Clinical Features Crepitation sounds from joint(s) Restricted or normal mouth opening capacity Pain or no pain from joint areas and/or of

mastication muscles Occasionally, joints may show inflammatory

signs Women more frequent than men

anteriorly displaced and deformed, degenerated disc and irregular cortical outline with osteophytosis and sclerosis of condyle .

Advanced osteoarthritis and anterior disc displacement, with joint effusion

Imaging Features•Abnormal signal on T2-weighted image fromcondyle marrow: increased signal indicates marrow edema; reduced signal indicates marrow sclerosis or fibrosis

•Combination of marrow edema signal and marrow sclerosis signal in condyle most reliable sign for histologic diagnosis of osteonecrosis

•Marrow sclerosis signal may indicate advancedosteoarthritis without osteonecrosis, or osteonecrosis

Definition Inflammation of synovial membrane

characterized by edema, cellular accumulation, and synovial proliferation (villous formation).

Clinical Features Swelling of joint area, not frequently seen in TMJ Pain (in active disease) from joints Restricted mouth opening capacity Morning stiffness, in particular stiff neck Dental occlusion problems; “my bite doesn’t fit” Crepitation due to secondary osteoarthritis

After 1 year

Rheumatoid arthritis. A MRI shows completely destroyed disc, replaced by fibrous or vascular pannus and cortical punched-out erosion (arrow) with sclerosis in condyle.

Psoriatic arthropathy. Oblique coronal and oblique sagittal CT images show punched-out erosion in lateral part of condyle (arrow).

Psoriatic arthropathy. MRI shows contrast enhancementwithin bone erosion and in joint space, consistent with thickened synovium/pannus formation. OpenmouthMRI shows reduced condylar translation but normallylocated disc (and normal bone in this section)

Inflammatory arthritis

DefinitionFibrous or bony union between joint components.

DefinitionAbnormal growth of mandibular condyle; overgrowth, undergrowth, or bifid appearance.

Normal TMJ

Condylar Hypoplas

ia

Condylar hypoplasia and facial asymmetry

Bifid condyle.

Calcium Pyrophosphate Dehydrate CrystalDeposition Disease (Pseudogout)

Synovial Chondromatosis Benign tumor characterized by cartilaginous

metaplasia of synovial membrane, usually in knee, producing small nodules of cartilage, which essentially separate from membrane to become loose bodies that may ossify.

Different pathologies affecting the masticatory muscles, the temporomandibular joint (TMJ), and related structures

Affects more than 25% of the population

90% of those seeking treatment are women

Facial pains/Muscle spasms

Pain/tenderness in the muscles of mastication and joint

Joint sounds (popping, clicking)

Limited jaw motion Jaw locking open or

closed Headaches Teeth grinding Abnormal swallowing

Uncomfortable “off” bite

Inability to comfortably open/close mouth

Dizziness/vertigo Ringing in the ears Visual disturbances Insomnia Tingling in

hands/fingers Deviation of jaw to one

side

Osseous Anatomy The articulation between the condyles of the

mandible and the temporal bone, which is part of the cranium.

The articular surface of the condyle is convex and the articular eminence of the temporal bone is concave.

Working together: Dentists Orthodontists Psychologists Physical Therapists Ear, Nose, Throat Doctor Physicians Alternative Medicine

MRI X-Ray Dental examination for bite alignment

Physical Therapy is an important aspect in the treatment for TMD to: Relieve

musculoskeletal pain Decrease

inflammation Restore normal

joint/muscular movements for oral motor function

Correct poor posture

History Posture Watch, feel, listen to jaw with AROM

Opening between 40-50mm Protrusion/retraction between 8-10mm Lateral deviation while opening (S or C curve) Lateral excursion 8-10mm

Ligamentous Laxity testing Transverse Ligament Alar Ligament

Cervical ROM testing Palpate joints/muscles for tenderness

Therapeutic Exercises

Manual Therapy Modalities Electromyographic

(EMG) Biofeedback Dental Splint

Improve muscular coordination

Increase muscular strength

Postural exercises Active ROM

exercises

Muscles of mastication

Cervical spine muscles

General mobility

Make a “clicking” sound with the tongue on the roof of the mouth. This slightly opens the jaw with the tongue on the palate behind the front teeth, which is the resting position of the jaw and the first portion of relaxation exercises.

Place tip of tongue on palate behind teeth and draw small circles.

Place tip of tongue on hard palate and blow air out, rolling the tongue, or making a “r r r r” sound.

Begin with proper resting position of the jaw. Teach the patient control while elevating and depressing the mandible throughout the first half of the ROM.

Keeping the tongue on the roof of the mouth, the patient opens the mouth while trying to keep the chin in midline. Use a mirror for visual reinforcement.

If the jaw deviates to one side, teach the patient to practice lateral deviation to the opposite side without creating pain or excessive motion.

Long Axis Distraction: Sitting/Supine PT positioned opposite

of affected side Use hand opposite of

affected jt. side Thumb in mouth on last

molar Apply gentle downward

pressure with thumb Hold for ~30 seconds

2-3x/session Bilaterally

Anterior Glide Same hand

placement Slightly distract

using DIP of thumb while gliding anteriorly

Oscillate for 30 seconds

Lateral Glide Thumb on tongue side of last molar Use whole hand to oscillate laterally

Medial Glide Stand on affected side Thumb on lateral side of last molar Glide medially

Avoid: Large bites Excessive chewing Removing food from

teeth with tongue Gum chewing Chewy foods: bagels,

sandwiches, steak, ice, crunchy fruits/vegetables, caramel, nuts etc.

Relaxation techniques to reduce stress/muscle tension

Maintain good posture

5-10 % dx w/TMJ Dysfunction fail to have relief of medical tx, and require surgery

Antiinflammatories, soft diet, hot compresses, muscle relaxants

>2 weeks: intraoral occlusion splints, med tx

Recurrent or chronic: permanent dental correction

Patient Factors Outpatient H& P, Blood chemistries, CBC, PT, PTT, U/A,

serum HCG, Chest x-ray or ECG as appropriate Room Set-up

X-rays in room

Position during procedure Supine w/head donut pillow, tuck arms to side

Supplies and equipment Arm sleds, headring pillow

Special considerations: high risk areas Elbows—ulnar nerves

Prep Shave preauricular area Cotton to ears to prevent pooling of povidone-iodine

& caution w/eyes; entire facial area prepped from hairline, down to shoulder, and laterally to include mouth and chin

Special considerations Nasal intubation Prophylactic antibiotics & steriods

State/Describe incision Small stab incision w/# 11 before trocar is

introduced at superior joint space

General: basic pack drape and split head sheet, gowns & gloves, towels, basin set, prep set, sterile adhesive wound drape, irrigation pouch, skin marker, raytex,

Specific Suture & Blades (# 11) Medications on field (name & purpose) Catheters & Drains: n/a Drapes: head turban for initial drape; pad pt forehead

with a folded towel; plastic adhesive wound drape to cover ET tube and mouth; split sheet and large sheet for body drape, (laser: 4 wet towels around pt’s face; moistened cotton in external auditory canals, irrigation collection pouch at base of ear and TMJ)

2 60 mL syringes 4 10 mL syringes 1 1-mL syringe Needles: 18 g, 21 g, 25 g Skin stapler Eye pads Sterile water and saline 1000 mL Lactated Ringers for irrigation 30 in extension tubing Stopcock

General: suction, Lactated Ringer’s IV bag for irrigation, marking pen

Specific TMJ instrument set

0 degree arthroscope 30-degree arthroscope 70-degree arthroscope Cannulas Sharp & dull obturators

Light cord, camera & cord, small joint rotary shaver

General: suction system Specific

Monitor/light source/camera tower, shaver control unit, IV pole for irrigant

Fluid infusion system Bipolar ESU Holmium laser

Irrigation solution is injected into the joint space to distend the capsule LR solution is preloaded in syringe w/needle attached.

After small stab incision is placed, surgeon inserts a sheath w/sharp obturator into superior joint space. After space is entered, the sharp is replaced with a dull obturator to further direct the sheath into the joint without damaging the intraarticular tissue or adjacent neurovascular structures. #11 blade with # 7 handle will be ready Trocar/cannula is preassembled. Expect trocor to be

returned. Be prepared to assist with connections of video/light cord connections.

Irrigation is infused into the joint LR solution is connected to the cannua via

extension tubing Joint is examined

Prepare to operate remote control for still photos

If functional surgery is needed, a second stab wound is made Pass skin knife. Prepare additional equipment

(probe, shaver, grasper) Final visual inspection is performed

Additional photos may be taken

Cannuale are removed and excess fluid removed Prepare for closure; count

Wound is closed and dressing placed Pass suture; prepare dressings, reorganize

equipment & supplies if procedure is bilateral Steps may be repeated contralaterally

Repeat steps

Thank you