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Piper's Classification of Intracapsular Temporomandibular Disorders

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Christine Chny

on 18 March 2014

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Transcript of Piper's Classification of Intracapsular Temporomandibular Disorders

Christine Joy S. Chny, DMD
Classification of Intracapsular Disorders
Piper’s Classification
Perforation with Acute Degenerative Joint Disease
STAGE VA
Stage VA
PERFORATION WITH ACUTE DJD
Laxity of the ligaments makes disk derangement possible if
muscle incoordination is allowed to exert tensive force on the disk.
If the disk is not deformed and a peaceful neuromusculature can be maintained, laxity of the ligament is not in itself a sufficient cause for disk displacement.
LIGAMENT
Piper’s Classification considers five general stages of intracapsular
disorders along with three subgroups of bony alterations

Piper's Classification
There are 7 structural elements to evaluate pain:
Piper's Classification
Piper's Classification
Piper’s Classification for intracapsular TMDs relates specific structural disorders to the progressive patterns that routinely occur as TMJs go through stages from health to severe degeneration.
1) Disk alignment
2) Disk shape
3) Ligament
4) Joint Space
5) Muscles
6) Bone Surfaces
7) Pain

DISK ALIGNMENT
Normal disk alignment positions the disk on the condyle so that all compressive forces are directed through its avascular, noninnervated bearing area.
Variations in disk alignment have major implications related to signs and symptoms of TMDs.

Important: analyze disk alignment at both the medial and lateral poles of each condyle.

NORMAL DISK ALIGNMENT
DISC DISPLACED
Displaced off lateral pole
still aligned on medial pole
DISK SHAPE
Determining whether the disk is elongated, folded, or
deformed into a compressed mass can explain variations in joint signs and symptoms and is often a determinant in treatment selection and prognosis.
NORMAL DISK SHAPE
DEFORMED DISK
NORMAL LIGAMENT
STRETCHED (LAX) LIGAMENT
JOINT SPACE
The “space” between the condyle and fossa is not a
void. It is the result of radiolucency of the disk and appears as a dark space on the film that represents the thickness of the disk.
If the disk is displaced, the condyle moves higher into the fossa and the space is diminished.
NORMAL JOINT SPACE
ABNORMAL CLOSED SPACE
MUSCLE
There will always be a reason for any muscle to be hyperactive,
and the most common primary causes in the masticatory
musculature will be either trauma or some form of
structural disharmony or deflective occlusal interference.
Even when emotional stress levels are
high, or clenching and bruxing is evident, there will almost
always be a structural disharmony present that serves as a
direct trigger for specific muscle incoordination.
Coordinated muscle is typically comfortable and is not tender to palpation
Uncoordinated muscle is
typically tender to palpation
BONE SURFACES
Signs may range from mild surface changes on the condyle and eminence to complete destruction of the condyle.
NORMAL BONE SURFACES
ALTERED CONDYLE AND EMINENCE
PAIN
Analysis of the type, location, and severity of pain
Important aspect of this analysis is the determination of whether intracapsular structures are the source of any, all, or none of the pain
Compressive loading of the joints in different jaw positions is the most effective way to determine this.
LATERAL POLE
MEDIAL POLE
LATERAL PTERYGOID
MASSETER
STAGE I STRUCTURALLY INTACT TMJ
Disk alignment should be normal at both poles
DIAGNOSIS
History of click
Load testing
Doppler
Imaging
Range and path of motion
Negative
Negative
Negative
Normal
Normal
Muscle palpation
The medial pterygoid muscle will almost always be tender to some degree when palpated, if the same side condyle has to displace from centric relation in order to achieve maximum intercuspation.

No laxity of ligaments and no alteration of bone surfaces.
Therefore, the disk cannot displace.
The treatment is focused on eliminating the causes of masticatory muscle hyperactivity with particular attention to complete elimination of any deflective inclines that can activate the lateral pterygoid muscle.
Distinguishing characteristics of Stage I.
Stage II INTERMITTENT CLICK
This stage is characterized by beginning laxity of the lateral diskal ligament in combination with lateral pterygoid muscle hyperactivity.
Disk displacement is reversible if muscle coordination is re-established.
History of click
Load testing
Doppler
Imaging
Range and path of motion
Pain source
DIAGNOSIS
Intermittent
Negative
Possible mild crepitus on translation only
Normal
Variable
Muscle
Lateral pterygoid
Intermittent clicking is evidence of some laxity of the posterior ligament combined with tensive pull on the disk by the superior lateral pterygoid muscle.
Clicking and temporal headaches on awakening
are common findings associated with nocturnal bruxing.
Signs and symptoms at this stage can almost always be completely eliminated by occlusal correction.
Examine for: excessive occlusal wear, hypermobility or sensitivity of interfering teeth, abfractions, and other progressive signs of tooth damage.
IMPLICATIONS (STAGE II)
STAGE IIIA LATERAL-POLE CLICK
Implications (STAGE IIIA)
A sure sign of muscle tension on the disk, and elongation of the posterior ligament at the lateral pole.
Occlusal correction is usuallyeffective in stopping the click in most III a disk derangements.
Most patients experience closed locks and escalation of symptoms.
History of click
Load testing
Doppler
Imaging
Range and path of motion
Pain source
DIAGNOSIS
Yes (reciprocal)
Negative if muscle contraction is released
Quiet on rotation; click and crepitus on translation
Normal
Variable
Muscle
Muscle tension
Elongation of the posterior ligament
STAGE IIIA LATERAL-POLE CLICK
STAGE IIIB LATERAL-POLE LOCK
History of click
Load testing
Doppler
Imaging
Range and path of motion
Pain source
DIAGNOSIS
This is the last stage of disk derangement that is treatable with fairly predictable long-term stability of the TMJs.
If the occlusion is perfected while the disk still covers the medial pole and adapted centric posture can be verified, we have seen almost no progression to Stage IV.
Had a click that disappeared
Negative when condyles are completely seated
Quiet on rotation; crepitus on translation
Normal transcranial; MRI Disk displaced off lateral pole only
May vary from normal
of motion to abnormal paths and
restriction of opening
Mostly muscle; some
retrodiskal compression
possible
Implications (STAGE IIIB)
Stage IIIB LATERAL-POLE LOCK
Disk displaced off lateral pole only
Disk still covers the medial pole
Disk derangement
STAGE IVA MEDIAL-POLE CLICK
DIAGNOSIS
History of click
Load testing
Doppler
Imaging
Range and path of motion
Pain source
Reciprocal click
Pain if not reduced; if reduced, can accept loading
Click; crepitus on rotation and translation
Normal if disk is reduced; space closed if disk is displaced
Variable from normal to restricted and deviated
Compression of retrodiskal tissue; muscle pain
IMPLICATIONS (STAGE IVA)
Since the disk is still reducible on to the medial pole, occlusal correction is sometimes all that is needed to prevent incoordinated muscle contraction (superior lateral pterygoid) from displacing the disk.
Compression of retrodiscal tissue
STAGE IVB MEDIAL-POLE LOCK
History of click
Noise
Load testing
Doppler
Imaging
Pain source
DIAGNOSIS
Had click that disappeared
May be none present
Tender to gentle loading in early stages
Crepitus on all movements
Space closed above and behind condyle
MRI Disk displaced off both poles

Compression of retrodiskal tissue; muscle pain
STAGE IVB MEDIAL-POLE LOCK
At this stage, it is very doubtful that the disk can be recaptured and maintained on the medial pole. Progression is a certainty that typically leads to painful loading of the retrodiskal tissues

Perforation
Osseous changes
Loss of condylar height
Excessive posterior tooth wear.

If the disk displaces medially, there is an increased potential for avascular necrosis.
History of click May have had an injury; may have had a click that disappeared
Noise Rough, grating sounds; can be palpated; probably no click
Load testing Usually painful
Doppler Coarse crepitus
Imaging (transcranial) Joint space closed; cortical bone deformed
MRI Shows extent of marrow death and location and contour of disk
Pain source Retrodiskal compression; articular surface breakdown;
muscle tenderness
Implications
At this stage, permanent irreversible changes in the occlusion are evident.
Specific diagnosis of the type of degenerative joint disease (DJD) is essential, so appropriate imaging is critical.
STAGE VB
Perforation with Chronic Degenerative Joint Disease
History of click Had a click that disappeared
Noise Palpable crepitus
Load testing Can usually load with no discomfort
Doppler Coarse crepitus on all movements
Imaging Flattened condyle and eminence
Pain source Usually muscle
DIAGNOSIS
DIAGNOSIS
STAGE VB
Perforation with Chronic Degenerative Joint Disease
Implications
This is the most common progression of TMJ deformation that occurs after complete disk displacement.
The bone-to-bone TMJ relationship to the fossae can, in most patients, accept firm loading with no discomfort.
In most of these patients, it is possible to achieve adapted centric posture.
Explain to these patients that the problem is manageable but to expect a need for periodic occlusal readjustment to maintain a peaceful neuromusculature.
Piper has expanded the classification system to include all types of disorders of the condylar head including:
1. Condylar hyperplasia
2. Osteochondrosis
3. Osteoarthrosis
4. Osteochondritis dissecans
5. Avascular necrosis

CONDYLAR HYPERPLASIA
OSTEOCHONDROSIS
Characterized by interruption of the blood supply of a bone, in particular to the epiphysis, followed by localized bony necrosis, and later, regrowth of the bone.
This disorder is defined as a focal disturbance of endochondral ossification and is regarded as having a multifactorial etiology
OSTEOARTHROSIS
3 main symptoms:
Pain
Morning stiffness
A tendency for the affected joint to gel with immobility
Osteochondritis dissecans
A joint disorder in which cracks form in the articular cartilage and the underlying subchondral bone.
AVASCULAR NECROSIS
A disease where there is cellular death (necrosis) of bone components due to interruption of the blood supply.
Frontal view of the wrist shows increased density and partial collapse of the proximal pole of the scaphoid (blue arrow)
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