INFLAMMATORY AND DEGENERATIVE PATHOLOGIES OF ATM

INFLAMMATORY AND DEGENERATIVE PATHOLOGIES OF ATM

PLAN :

1. INTRODUCTION 
2. ANATOMOPHYSIOLOGICAL REMINDER
3. ORGANIC PATHOLOGIES OF ATM
   1. Septic arthritis 
   2. Inflammatory arthritis 
      1. Rheumatoid arthritis 
      2. juvenile chronic arthritis 
      3. ankylosing spondylitis
      4. psoriatic arthritis 
   3. degenerative lesions or osteoarthritis  
   4. osteonecrosis of the condyle
   5. condylar malformations
   6. condylar tumors
4. CONCLUSION 
5. INTRODUCTION : 

The temporomandibular joint is a bicondylar diarthrosis  with interposed meniscus. Their synchronous functioning means that any abnormality of one of the TMJs ultimately affects the other. The various organic pathologies are inflammatory, malformative and tumoral. Often, the diagnosis of these pathologies remains difficult and their management complex .

2. ANATOMOPHYSIOLOGICAL REMINDER:
   1. Anatomy: 

The temporomandibular joint is a paired joint that joins the mandible to the temporal bone. 

It is a joint:

• complex synovial
• Bicondylar

The articular surfaces are:

• The Glenoid Cavity 
• The Mandibular Condyle

The capsule is a fibrous, collagenous sleeve that encircles the entire TMJ and adheres to the rim of the disc 

the synovium  : Is a serous membrane lining the deep surface of the joint capsule, it is thin and secretes a viscous colorless joint lubrication liquid.

The disc: fibrocartilage, which will be interposed between the two articular surfaces

• elliptical
• the shape of a biconcave lens
•  non-vascularized and non-innervated

 Its position allows the ATM to be divided into two parts:

• the disco-temporal articulation
• the discomandibular joint

2. Physiology: 

• The essential functions performed by the ATMs are mouth opening and chewing.
• ATMs operate simultaneously 
• In each ATM: sliding movements are carried out: in the disco-temporal joint, and rotational movements in the disco-mandibular joint 
• there are 10,000 movements / 24 hours.

3. ORGANIC PATHOLOGIES: 

The temporomandibular joint has structures identical to those of other joints. It can therefore be the site of various inflammatory or degenerative rheumatisms.

In addition, its own anatomical and physiological characteristics (disc) give it some physiopathological originalities.

1. SEPTIC ARTHRITIS: 

Cause:

• joint fracture during trauma 
• the extension of a neighboring condition (parotitis, masseteric cellulitis)
• a hematogenous localization of septicemia.

The germs involved:

• staphylococci++++
• in subacute and chronic arthritis: Actinomyces/Koch’s bacillus

Clinical Signs:

• signs of inflammation: pain, hyperthermia, swelling
• lockjaw
• painful attempts at mobilization.

Radiological signs:

• no abnormality in the initial phase

After a week:

• hyper bone transparency
• a pinching of the joint space
• unclear and poorly defined bone erosions
• Irreversible damage

Evolution :

• an intra-articular suppurative collection
• accentuation of trismus
• alteration of general condition           
• Fistulization
• temporomandibular ankylosis.

INFLAMMATORY AND DEGENERATIVE PATHOLOGIES OF ATM

Treatment :

• Antibiotic therapy: the combination of two bactericidal and synergistic antibiotics, essential in attack treatment.
• Joint evacuation
• mandibular immobilization by intermaxillary blocking
• Gentle and progressive mobilization, several times a day once the infection is under control.

2. INFLAMMATORY ARTHRITIS OF GENERAL ORIGIN: 
3. RHEUMATOID ARTHRITIS:

• Rheumatoid arthritis is characterized by aggressive synovitis, secondarily responsible for bone erosions.  
• Joint destruction is often severe and functionally disabling.
• This condition is often bilateral and symmetrical. It initially affects the small peripheral synovial joints before spreading to the rest of the skeleton.
• Dysregulation of cell-mediated immunity including synovial membrane
• Touch Women +++ (30 and 50 years old) 
• ATM is affected 3 years after the onset of the disease
• Clinically: unilateral pain, accompanied by sensations of rubbing when opening the mouth
• The radiological assessment is normal for a very long time
• The amount of synovial fluid is increased, ++ fluid and its lubricating and nutritional qualities are also altered 
• the evolution goes towards an alteration of the bone surfaces
• Treatment is done by a rheumatologist

2.  CHRONIC JUVENILE ARTHRITIS:

• Acute or subacute onset forms generally begin between 2 and 7 years of age with fever, erythema, lymphadenopathy, splenomegaly and arthralgia, particularly affecting the knees, wrists and ankles. 
• The ATM is rarely affected in this form. 
• The evolution is generally favorable thanks to corticosteroid therapy
• Chronic forms appear immediately around the age of 8, with ++ female.. the condyles are reduced in volume, with irregular contours, or even totally destroyed.

3.2.3. ANKYLOSING SPONDYLITIS

• Ankylosing spondylitis is a common condition, mainly in men, and affects the TMJ in 24% according to Resnick (1974)
• In the vast majority of cases, there are spinal and sacroiliac manifestations which are revealing (60%) and which continue to dominate the clinical picture later.

Clinical signs:

• A progressive limitation of mouth opening 
• Spontaneous pain and tenderness on palpation of the TMJ

Radio signs:

• condylar erosions + signs of osteophytes.
• The scan reveals bone destruction.
• Advanced forms result in complete bony ankylosis of the joint.

Treatment in rheumatology

3.2.4. PSORIATIC RHEUMATISM  

• Psoriatic arthritis belongs to the group of spondyloarthropathies.
• Localization at the ATM level is relatively uncommon.
• Radio: bone erosions.
• Diagnosis: existence of psoriasis (cutaneous or nail)
• associated with manifestations: Articular (pain, swelling and/or limitation of mobility of at least one joint 
• the presence of “sausage” fingers or toes
• The treatment is similar to that of chronic inflammatory rheumatism: analgesics, non-steroidal anti-inflammatory drugs (apart from aspirin which is classically contraindicated, as is general corticosteroid therapy). 

3. DEGENERATIVE LESIONS: TEMPOROMANDIBULAR ARTHROSIS

• Temporomandibular osteoarthritis reflects the wear and tear of all joint structures (cartilage, bone and meniscus).
• can sometimes be the result of long-standing temporomandibular dysfunction or appear spontaneously 
• sometimes following certain fractures of the mandible (capital fracture of the condyle).
• The beginning is gradual
• It affects people over 40 years old
• The signs are often unilateral
• It manifests itself by:
  – joint pain aggravated by joint function, chewing or speaking,
  – joint noises: grinding
  – a limitation of mouth opening
• slowly evolving
•  Its treatment
  **symptomatic with analgesics and anti-inflammatories
  **surgical if disabling pain +/- limitation of mouth opening
  **prosthetic rehabilitation of posterior edentulousness
• INFLAMMATORY AND DEGENERATIVE PATHOLOGIES OF ATM

Radiologically: 

• Geodes, an osteophyte at the bone-cartilage junction.
• MRI visualizes flattening and loss of sphericity of the condyles, and the presence of osteophytic formations. 

4. OSTEONECROSIS OF THE CONDYLE

• Mainly affects the young girl 
• Manifested by joint pain and limited mouth opening . 
• Occurs after trauma

MRI: Condylar necrosis results in heterogeneity of the articular surfaces

• Evolves spontaneously within a few months towards healing of osteonecrosis with remodeling

5. MALFORMATIONS: CONDYL AGENESIS AND HYPOPLASIA

Sometimes there are congenital lesions resulting in agenesis or hypoplasia of the temporomandibular joint.

6. CONDYLAR TUMORS: 

• tumors of bone, cartilaginous or synovial origin. 
• non-specific intra-articular clinical manifestations: local pain, dysfunctional-appearing symptoms, limited mouth opening, laterodeviation 
• Later, swelling appears in the joint region.

4. CONCLUSION: ATM disorders are of multifactorial origin. In forms resistant to conservative treatment, as for all chronic diseases, management is more complex and may require a multidisciplinary and surgical approach. It is therefore important to avoid aggressive and irreversible therapeutic approaches as first-line treatment. Treatment must be based on a solid diagnosis.

INFLAMMATORY AND DEGENERATIVE PATHOLOGIES OF ATM

  Wisdom teeth can be painful if they are misplaced.
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Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.
 

INFLAMMATORY AND DEGENERATIVE PATHOLOGIES OF ATM