Ministry of Health of Ukraine Higher State educational institution of Ukraine "Ukrainian Medical Stomatological Academy"

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1 Ministry of Health of Ukraine Higher State educational institution of Ukraine "Ukrainian Medical Stomatological Academy" Approved the meeting of department Pediatric surgical stomatology with propaedeutics of surgical stomatology " " 20 r. protocol number Chair, DMS., profesor Tkachenko P.I. GUIDELINES for students' independent work during training to practice Educational discipline Module number 1 Pediatric surgical stomatology Inflammation in maxillofacial region in children. General characteristics of inflammation in maxillofacial region in children. Inflammatory processes of the jaws (abscess, osteomyelitis). Content module number 2 Inflammatory diseases of the temporomandibular joint (arthritis, osteoarthritis, ankylosis). Inflammatory odontogenic cysts of the jaws from deciduous and permanent teeth. Anatomical and functional features of TMJ at Topic of classes children depending of age. Clinical examination of patient with TMJ pathology, classification of diseases. Course 4 Faculty stomatological Poltava-2016

2 1. Relevance of the topic. Patients frequently consult a dentist because of pain or dysfunction in the temporomandibular region. The most common causes of temporomandibular disorders (TMDs) are muscular disorders, which are commonly referred to as myofascial pain and dysfunction. These muscular disorders are generally managed well with a variety of reversible nonsurgical treatment methods. 2. Specific objectives: 1.To know: features of anatomical annd histological structure of TMJ at children of different ages, classification of diseases, their clinical symptoms, diagnostics and methods of treatment. 2. To be able: to collect anamnesis of life and disease of child, to make diagnosis, to define the methods of treatment. 3.To seize: by the methods of differential diagnostics and prescribe the conservative treatment. 3. Base knowledge, abilities, skills necessary for studying of a theme (interdisciplinary integration). Disciplines To know To know how 1. Previous. Histology Stages of embryogenesis of face. Schematically to represent the embryogenesis of person. Anatomy 1. General description of joints. Schematically to 2. Age-depending features of TMJ represent the elements of Proupedeutics of internal and surgical diseases Clinical pharmacology 2. Following. Orthodontics Proupedeutics of surgical dentistry structure. 1. Methods of evaluation of patients with the TMJ diseases. 2. Principles and mechanism of medical action of different types of physiotherapy. Features of pharmacodynamics and pharmakokinetics of hormonal and unhormonal resolvents and antibiotics. Maloclusion at children with TMJ pathology. Etiology and pathogeny of TMJ diseases at children and methods of their diagnostics. TMJ 1. To conduct the basic and special methods of examination of joints. 2. To conduct physical therapies procedures at patients. To be able to write the recipes of medications for this patients. To consist plan of complex treatment. To make diagnosis, consist a plan of rehabilitations measures A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson: Term Definition TMJ temporomandibular joint, The name is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jaw bone called the mandible TMD temporomandibular disorder 4.2. Theoretical problems for the classes: 1. Structure and functions of TMJ. 2. Clinical evaluation of TMJ. 3. Classification of TMJ diseases Practical work (tasks) are performed in classes: 1. Examination of thematic patients.

3 2. To fill up case history. 3. To examine of TMJ. Theme contents: Anatomy of TMJ. The TMJ is the most complex joint in the body. It provides for hinging movement in one plane (a ginglymoid joint), and at the same time provides for sliding movements (an arthrodial joint). Therefore, it is technically a ginglymoar-throdial joint. The TMJ is classified as a compound joint i.e., requiring the presence of at least three bones. The articular disc is composed of dense fibrous connective tissue devoid of any blood vessels or nerve fibers. Functionally it serves as a non-ossified bone that permits the complex movements of the joint. The articular disc can be divided into central, anterior and posterior regions. The central area, the intermediate zone, is the thinnest. The anterior border is generally slightly thinner than the posterior border. From an anterior view, the disc is generally thicker medially than laterally, which corresponds to the increased space between the condyle and the articular fossa toward the medial aspect of the joint. On opening, the superior surface of the articular disc has a sigmoid shape. The disc is firmly attached downward to the medial and lateral poles of the condylar head. The disc is the primary storage site for synovial fluid. The retrodiscal tissue, or posterior attachment, consists of an area of loose connective tissue that is attached to the posterior aspect of the articular disc. It is highly vascularised and innervated, and is bordered superiorly by the superior retrodiscal lamina. The superior retrodiscal lamina consists of connective tissue containing many elastic fibers. It attaches the articular disc posteriorly to the tympanic plate. Its function is to counter the forward pull of the superior belly of the lateral pterygoid muscle on the articular disc. When the mouth is fully opened, the retrodiscal tissue is fully stretched. The superior retrodiscal lamina prevents the disc from dislocating anteriorly, and also results in posterior rotation of the meniscus allowing the thin intermediate portion of the disc to remain between the articular surfaces of the condyle and eminence. The inferior retrodiscal lamina consists mainly of collagenous fibers. It is located at the lower border of the retrodiscal tissues. It attaches the inferior border of the posterior aspect of the disc to the posterior margin of the articular surface of the condyle. Posteriorly, the remaining body of the disc is attached to a large venous plexus that fills with blood as the condyle moves forward. Anteriorly, the superior and inferior aspects of the disc are attached to the capsular ligament, which surrounds most of the joint. The superior and inferior attachments are to the anterior margins of the articular surface of the temporal bone and condyle respectively. The disc is also attached by tendinous fibers to the superior lateral pterygoid muscle, between the attachments of the capsular ligament. The TMJ disk is a biconcave fibrous structure located between the mandibular condyle and the temporal component of the joint. The disk is round to oval, with a thick periphery and a thin central part. The mediolateral dimension of the disk is approximately 20 mm. In a sagittal section the normal disk appears biconcave, with the anterior and posterior thicker parts of the disk, respectively, referred to as the anterior and posterior bands. The articular disc is attached to the capsular ligament anteriorly and posteriorly, as well as medially and laterally. This divides the joint into two distinct cavities. The internal surfaces of the cavities are surrounded by specialized endothelial cells that form a synovial lining. This lining, along with a specialized synovial fringe located at the anterior border of the retrodiscal tissues, produces synovial fluid that fills both joint cavities. The articular surfaces of the mandibular fossa and condyle are lined with dense fibrous connective tissue rather than hyaline cartilage, as in most other mobile joints. The fibrous connective tissue in the joint affords several advantages over hyaline cartilage; it is generally less susceptible to the effects of aging and therefore less likely to break down over time, and has a much greater ability to repair.

4 The TMJ is composed of the condyle (mandible) and the articular (or glenoid) fossa of the temporal bones, bilaterally. The temporal bone consists of five parts: squamous, petrous, internal acoustic meatus, zygomatic, and middle cranial fossa. The facial nerve (motor control over the facial muscles) and the vestibulocochlear nerve (balance and hearing) both travel the course of the internal acoustic meatus. The middle cranial fossa is the floor, which supports the brain stem from which the cranial nerves originate. The connection between the TMJ and the middle ear is through the petro-tympanic fissure. This runs the length of the glenoid fossa. The condyle may have several different normal shapes. The shape should be the same right to left. A flat condyle surface on one side may be pathologic if the contra-lateral side is angled. Condyles that are both angled or both flat may be normal contours. The TMJ is referred to as a synovial joint. The articular disc is the primary source of synovial lubricant within the TMJ. The synovial fluid acts as a medium for providing metabolic requirements to these tissues. There is free and rapid exchange between the vessels of the capsule, the synovial fluid, and the articular tissues. The inferior joint space contains about 0.9 ml of synovial fluid, and the superior joint space contains about 1.2 ml of synovial fluid. The synovial fluid also serves as a lubricant between articular surfaces during function. The articular surfaces of the disc, condyle, and fossa are very smooth this minimizes friction during movement. The synovial fluid helps to further minimize this friction. This lies on the condylar head like a cap and drapes over all surfaces, but extends most caudad to the condylar neck in its posterior aspect. When the mandible is depressed, the inferior joint space opens to a greater extent posteriorly, giving the appearance in lateral view of a teardrop in the inferior joint space posterior to the condylar head. The anterior portion of the inferior joint space forms a small fossa where the fibers of that capsular ligament and the anterior band of the disc form a concretion. This sling-like structure helps to stabilize the disc against the condylar head during function. This is larger and more anteriorly placed than the inferior joint space. Its shape in the cephalad aspect corresponds closely to the glenoid fossa. On the caudad aspect, the concavity of the intermediate zone can be noted. The separation of the retrodiscal tissue from the posterior band is clearly differentiated when viewed from the superior joint space. The anterior fossa of the superior joint space forms a concavity in front of the condylar head. The medial fossa forms a concavity medial to the condylar head. The precise shape of the disc is determined by the morphology of the condyle and mandibular fossa. During movement, the disc is somewhat flexible and can adapt to the functional demands of the articular surfaces. However, flexibility and adaptability do not imply that the morphology of the disc is reversibly altered during function. The disc maintains its morphology unless destructive forces or structural changes occur in the joint. The joint is enclosed by a fibrous capsule, which is lined by a synovial membrane. This membrane is highly vascular and is continuous with the connective tissue of the capsule. Both upper and lower joint compartments are lined with their own synovial membrane. The synovial membrane allows diffusion of a plasma filtrate and components of its own to produce synovial fluid that fills both joint compartments. Its shape is altered during functional movement. The largest area of synovial tissue is on the superior and inferior retrodiscal lamina, where it forms small folds, or villi, that stretch on translation of the condyle and disc. The articulating surfaces of the temporal bone, the condyle, and the disc are not covered. The synovial tissue can be divided into three layers: 1. The synovial lining, or intima, is the most intimate with the functional joint surfaces. 2. The subsynovial tissue, which is similar to the intima but with a more developed connective tissue network. 3. The capsule, which is a relatively acellular layer with thick bands of collagen that forms the outer boundary of the joint.

5 Synovial surfaces are nonadherent. The cells on the surface bind to the underlying matrix but not to the opposing tissue. Constant movement against opposing surfaces is thought to break down any forming cross-links. Collagenase secretion by the synovial lining cells also helps prevent the formation of surface adhesions and ensures that fragmented collagen on the tissue surface does not activate the coagulation cascade. Synovial tissue has the ability to regenerate when damaged. Synovial fluid is a filtrate of plasma that passes through fenestrations in the subendothelial capillaries into the intercellular spaces. Because there is no epithelium, and hence no basement membrane, no barrier exists between the synovium and the fluid present in the joint spaces. Movement is mainly by passive diffusion. Function of TMJ. The function of the TMJ is complex because the upper and lower joint compartments principally act as two small joints within this same joint capsule. This allows for proportionally greater movement of the TMJ in relation to the actual size of the joint. The principal function of the disk is to permit relatively large movements within a small joint while maintaining stability. Rotation and translation occur in both the upper and lower joint spaces. However, translation occurs predominantly in the upper space, and rotation is more evident in the lower joint space. In the initial phase of jaw opening, the condyle rotates in the lower joint compartment. After this initial rotation, translation occurs in the upper and subsequently in the lower joint space. During translation, the condyle and the disk translate (slide) together under the articular tubercle. During all mandibular movements, the central thin part of the disk is located between the condyle and the articular tubercle. This suggests that the thick periphery of the disk and the thick posterior and anterior bands act as functional guides for the joint. This normal joint function can be identified in anatomic specimens of the TMJ. Etiology of TMD Temporomandibular disorders have multiple etiological fac-tors.10 Many studies show a poor correlation between any single etiological factor and resulting signs (findings identified by the dentist during the examination) and symptoms (findings reported by the child or parent).10 In fact, the TMJ and masticatory system is complex and, thus, requires a thorough understanding of the anatomy and physiology of the structural, vascular, and neurological components in order to manage TMD. Alterations in any one or a combination of teeth, periodontal ligament, the TMJ, or the muscles of masticationeventually can lead to TMD. Research is insufficient to predict reliably which patient will or will not develop TMD. Etiologic factors suggested as contributing to the development of TMD are: 1.Trauma: This would include impact injuries such as trauma to the chin. A common occurrence in childhood because of falling, chin trauma is reported to be a factor in the development of TMD in pediatric patients.unilateral and bilateral intracapsular or subcondylar fractures are the most common mandibular fractures in children. Closed reduction and prolonged immobilization can result in ankylosis. 2. Occlusal factors: There is a relatively low association of occlusal factors and the development of temporomandi-bular disorders. However, several features characterize malocclusions associated with TMD: skeletal anterior open bite; overjet greater than 6 to 7 mm; retrocuspal position (centric relation) to intercuspal position (centric occlusion) slides greater than 4 mm; unilateral lingual cross bite; 5 or more missing posterior teeth; Class III malocclusion. 3. Parafunctional habits (eg, bruxism, clenching, hyperextension, other repetitive habitual behavior): Bruxism is thought to contribute to the development of TMD by joint overloading that leads to cartilage breakdown, synovial fluid alterations, and other changes within the joint. These parafunctional habits may occur while the patient is asleep or awake.

6 4. Posture: Craniocervical posture has been associated with occlusion and with dysfunction of the TMJ, including abnormalities of the mandibular fossa, condyle, ramus, and disc. 5. Changes in free-way dimension of the rest position: Normally 2-4 mm, this may be impinged by occlusal changes, disease, muscle spasms, nervous tension, and/or restorative prosthetics. 6. Orthodontic treatment: Current literature does not support that the development of TMD is caused by orthodontic treatment, regardless of whether premolars were extracted prior to treatment. The evaluation of the patient with temporomandibular pain, dysfunction, or both is like that in any other diagnostic workup. This evaluation should include a thorough history, a physical examination of the masticatory system, and some type of routine TMJ radiography. Special diagnostic studies should be performed only as indicated and not as routine studies. All comprehensive dental examinations should include a screening evaluation of the TMJ and surrounding area. Diagnosis of TMD is based upon a combination of historical information, clinical examination, and/or craniocervical andtmj imaging. The findings are classified as symptoms and signs. For a diagnosis of TMD, patients must have a history of facial pain combined with physical findings, supplemented by radiographic or imaging data when indicated.58 A screening history, as part of the health history, may include questions such as: Do you have difficulty opening your mouth? Do you hear noises within your jaw joint? Do you have pain in or around your ears or your cheeks? Do you have pain when chewing? Do you have pain when opening your mouth wide or when yawning? Has your bite felt uncomfortable or unusual? Does your jaw ever lock or go out? Have you ever had an injury to your jaw, head, or neck? If so, when? How was it treated? Have you previously been treated for a temporomandib-ular disorder? If so, when? How was it treated? Examination The physical examination consists of an evaluation of the entire masticatory system. The head and neck should be inspected for soft tissue asymmetry or evidence of muscular hypertrophy. The patient should be observed for signs of jaw clenching or other habits. The masticatory muscles should be systematically examined. The muscles should be palpated for the presence of tenderness, fasciculations, spasm, or trigger points. The TMJs are examined for tenderness and noise. The location of the joint tenderness (e.g., lateral, posterior) should be noted. If the joint is more painful during different areas of the opening cycle or with different types of functions, this should be recorded. The most common forms of joint noise are clicking (a distinct sound) and crepitus (i.e., multiple scraping or grating sounds). Many joint sounds can be easily heard without special instrumentation or can be felt during palpation of the joint. However in some cases auscultation with a stethoscope may allow less obvious joint sounds, such as mild crepitus, to be appreciated. The mandibular range of motion should be determined. Normal range of movement of an adult's mandible is about 45 mm vertically (i.e., interincisally) and 10 mm protrusively and laterally. The normal movement is straight and symmetric. In some cases tenderness in the joint or muscle areas may prevent opening. The clinician should attempt to ascertain not only the painless voluntary opening but also the maximum opening that can be achieved with gentle digital pressure. In some cases the patient may appear to have a mechanical obstruction in the joint causing limited opening but with gentle pressure may actually be able to achieve near nor mal opening. This may suggest muscular rather than intracapsular problems. The dental evaluation is also important. Odontogenic sources of pain should be eliminated. The teeth should be examined for wear facets, soreness, and mobility, which may be evidence of

7 bruxism. Although the significance of occlusal abnormalities is controversial, the occlusal relationship should be evaluated and documented. Missing teeth should be noted, and dental and skeletal classification should be determined. The clinician should note any centric relation and centric occlusion discrepancy or significant posturing by the patient. The examination find- ings can be summarized on a TMD evaluation form and included in the patient's chart. In many cases a more detailed chart note may be necessary to adequately document all of th e history and ex amin ation find ings described previously. Radiographs of the TMJ are extremely helpful in the diag- nosis of intraarticular, osseous, and soft tissue pathology. The use of radiographs in the evaluation of the patient with TMD should be based on the patient's signs and symptoms instead of routinely ordering a "standard" set of radiographs. In many cases the panoramic radiograph provides adequate information as a screening radiograph in evaluation of TMD. A variety of other radiographic techniques are available that may provide useful information in certain cases. Transcranial radiographs. A standard dental radiographic unit combined with a headholding device can be used to produce a transcranial image of the TMJ. Although this view will not allow detailed examination of all aspects of the TMJ, excellent evaluation of the lateral pole of the condyle can be accomplished when the proper radiographic technique is used. Because bony pathology of the TMJ frequently extends to the lateral pole, this technique can be helpful in diagnosing bony internal joint pathology.' Panoramic radiography. One of the best overall radiographs for screening evaluation of the TMJs is the panoramic radiograph. This technique allows visualiza- tion of both TMJs on the same film. Because a panoramic technique provides a tomographic type of view of the TMJ, this can frequently provide a good assessment of the bony anatomy of the articulating surfaces of the mandibular condyle and glenoid fossa, and other areas, such as the coronoid process, can also be visualized. Many machines are equipped to provide special views of the mandible, focusing primarily on the area of the TMJs. These radiographs can often be completed in both the open and closed position. Tomograms. The tomographic technique allows a more detailed view of the TMJ.2 This technique allows radiographic sectioning of the joint at different levels of the condyle and fossa complex, which provides individual views visualizing the joint in "slices" from the medial to the lateral pole. These views eliminate bony superimposition and overlap and provide a relatively clear picture of the bony anatomy of the joint. Temporomandibular joint arthrography. This imaging method was the first technique available that allowed visualization (indirect) of the intraarticular disk. Arthrography involves the injection of contrast material into the inferior or superior spaces of a joint, after which the joint is radiographed. Evaluation of the configuration of the dye in the joint spaces allows evaluation of the position and morphology of the articular disk. This technique also demonstrates the presence of perforations and adhesions of the disk or its attachments. With the availability of more advanced, less invasive techniques arthrography is rarely used. Computed tomography. Computed tomography (CT) provides a combination of tomographic views of the joint, combined with computer enhancement of hard and soft tissue images. This technique allows evaluation of a variety of hard and soft tissue pathology in the joint. CT images provide the most accurate radiographic assessment of the bony components of the joint. CT scan reconstruction capabilities allow images obtained in one plane of space to be reconstructed so that the images can be evaluated from a different view. Thus evaluation of the joint from a variety of perspectives can be made from a single radiation exposure. Magnetic resonance imaging. The most effective diagnostic imaging technique to evaluate TMJ soft tissues is magnetic resonance imaging (MRI). This technique allows excellent images of intraarticular soft tissue, making MRI a valuable technique for evaluating disk morphology and position. MRI images can be obtained showing dynamic

8 joint function in a cinematic fashion, providing valuable information about the anatomical components of the joint during function. The fact that this technique does not use ionizing radiation is a significant advantage. Nuclear imaging. This technique involves injection of Tc", a gamma-emitting isotope that is concentrated in areas of active bone metabolism. Approximately 3 hours after injection of the isotope, images are obtained using a gamma camera. Single photon emission computerized tomography (SPECT) images can then be used to determine active areas of bone metabolism. Although this technique is extremely sensitive, the information obtained may be somewhat difficult to interpret. Because bone changes, such as degeneration, may appear identical to repair or regeneration, this technique must be evaluated cautiously and in combination with clinical findings. There is a need for improved classification of TMDs; however, they largely can be grouped into 3 classes: 1. Disorders of the muscles of mastication (including pro-tective muscle splinting, muscle spasm, and muscle inflammation); 2. Disorders of the TMJ (including internal disk derange-ment, disk displacement with reduction accompanied by clicking, and anterior disk displacement without reduc-tion seen as mechanical restriction or closed lock); 3. Disorders in other related areas that may mimic TMD (eg, chronic mandibular hypomobility, inflammatory joint disorders such as juvenile rheumatoid arthritis, degenerative joint disease, extrinsic trauma such as fracture). 5. Self-control materials. А. Questions to be answered: 1.Age features of TMJstructure. 2.Etiology, pathogeny and prevalence of TMJpathology at children. 3.Classification of TMJdiseases at children. 4.Reversible treatment. 5. Temporomandibular jointsurgery. B. Self-control tests: 1. Disfunction of TMJ is characteristic for age: 1) to 3th year; 2) 3-6 years; 3) 6-9 years; 4) 9-11 years; 5) more than 11 years. 2.The tonic spasm of mastication muscles presents by: 1) youth disfunction; 2) acute arthritis; 3) chronic arthrosis; 4) ankylosis. 3. The X-ray changes of osseous structures of TMJ are determined by: 1) disfunction; 2) acute arthritis; 3) chronic arthrosis. 4. The S-similar motions of lower jaw during opening of mouth are showed by? 1) disfunctions; 2) acute arthritis;

9 3) chronic arthrosis; 4) osseous ankylosis. 5. The reason of asymmetry of face by deforming osteoarthrosis of TMJ on one side is : 1) excalation of half of lower jaw; 2) paresis; 3) intermuscular haematoma; 4) hyperthrophy of masseter muscle; 5) displacement of disk. C. Tasks for self-control: 1. Child of 12 years old has complaints: pain and slight swelling in the region of left TMJ. Medical history: 2 days ago a child very widely opened a mouth and experienced great pain in left parotid region. Objective: in the region of left TMJ the slight swelling and hypodermic hemorrhage presents, palpation is painfull, opening of mouth is some limited, even, smooth, painfully. What disease may be diagnose? 2. The parents of 4 years old child has complaints: the abnormality of facial configuration at child. Objective: the middle line of chin is displaced to the left on 1 sm, the right corner of mouth is tomentous, opening of mouth on 0,6 см. Bite cross. To define a previous diagnosis? 3.The child (14 years old) has complaint: crunch in ear during opening of mouth which showed half year. Not found out concrete reasons which it was possible to link. Objective: a face is symmetric, proportional, opening of mouth is some limited. The smoothness of sliding of arthral heads from both sides is disorded. The painfull during palpation and motions in joints is not showed. What diagnosis is most reliable? Recommended literature: Main Sources: 1.Contemporary Oral and Maxillofacial Surgery (4th Edition) Larry J. Peterson (Editor), Edward Ellis (Editor) & James R Hupp Mosby-Year Book, Dec p. 2.Pediatric Oral and Maxillofacial Surgery by Leonard Kaban and Maria Troulis Publisher:W.B.Saunders,Mar p. Additional Sources: 1. Dolwick MF. Disc preservation surgery for the treatment of internal derangements of the temporomandibular joint, / Oral Maxillofac Surg 59:1047, McKenna SJ. Discectomy for the treatment of internal derangements of the temporomandibular joint, / Oral Maxillofac Surg 59:1051, Poswillo D. The effects of intraarticular deposition of betamethasone in the goat temporomandibular joint: discussion: / Oral Maxillofac Surg 52:1440, 1995.