0
Q
TMJ - Roles
A
Functional activities: -Mastication -Communication -Yawning -Laughing Parafunctional activities: -Bruxism (grinding of teeth) -Chewing pencils (talking involves 6,000 motions minimum)
1
Q
Semantics
A
- TMJ = temporomandibular joint
- TMD = temporomandibular disorders
2
Q
TMJ Anatomy - Overview
A
- Diarthrodial synovial joints
- Fibrous cartilage covers articular surfaces
- Fibrocartilaginous articular disc
- Construction: beneficial for rapid and smooth mandibular movement; vulnerable to failure (too little loading, too much loading)
3
Q
TMD Described
A
Any dysfunction involving the temporomandibular joint(s)
-Soft tissue
-Capsule
-Meniscus/disc
-Bone
(all structures have to work together for function)
4
Q
Anatomical Bony Review
A
Osseous structures
- Temporomandibular joint
- Zygomatic arch
- Mastoid process
- Mandible
- Hyoid
- C1
- C2
5
Q
Anatomical Joint Review
A
- superior lamina
- meniscus
- inferior lamina
- retrodiscal pad
- articulating surface on the condyle
6
Q
Anatomical Soft Tissue Review
A
- Masseter - sitting, supine, clenched, relaxed (elevates mandible or closes the mouth)
- Temporalis - sitting, supine, clenched, relaxed
- Sternocleidomastoid - sitting, supine (rotates head to opposite side, together-FL)
- Suprahyoid muscles - sitting, supine
- Infrahyoid muscles - sitting, supine (stretch weakness with FHP)
- Suboccipital muscles - supine
- Scaleni muscles - supine
- Pectoralis major & minor muscles
- Latissimus dorsi muscles
7
Q
Anatomical Neurogenic Review
A
- facial nerve and trigeminal nerve
- sharp electrical current in the face
8
Q
Biomechanics of TMJ - Overview
A
- Ginglymoarthrodial articulation (simple hinge joint)
- Osteokinematics:
- Depression
- Protrusion
- Lateral Excursion
- Arthrokinematics:
- Rolling & Spinning
- Distraction
- Anterior translation
- Lateral glide
9
Q
Biomechanics - Depression
A
- Opening of mouth in sagittal plane
- Normal range 40 mm
- First two knuckles in mouth = 20 to 25 mm (functional, but not normal)
10
Q
Biomechanics - Protrusion
A
- Movement of mandibular condyles in horizontal plane
- Lower incisors should at least meet upper incisors, ideally should move past by several mm
- Measure with ruler from superior teeth to inferior teeth
- Allows formation of sounds (His, church, house, etc)
11
Q
Biomechanics - Lateral Excursion
A
- Mandible moves laterally in horizontal plane (left and right)
- Normal lateral excursion = 8 mm
12
Q
Biomechanics - Deviation
A
- “S” curve
- Mandible moves away from midline during mandibular depression or protrusion
- Mandible returns to midline by end of movement
13
Q
Biomechanics - Deflection
A
- “C” curve
- Mandible moves away from midline during mandibular depression or protrusion
- Mandible does NOT return to midline
14
Q
NOTE Biomechanics
A
- Deviation or deflection may be a result of anomalies of the osseous structures
- In presence of good functional movement, may be considered insignificant and require no intervention
15
Q
Biomechanics - Mandibular Depression - Phase 1
A
- Rotation of condyle first 10 to 15 mm
- Condyle is convex on concave
- Rotation is posterior in relation to temporal bone
- After first 11 mm, condylar head translates anteriorly to achieve full functional opening
16
Q
Biomechanics - Mandibular Depression - Phase 2
A
-Accessory movement and anterior translation of condyle
-Starts at 10 to 15 mm of mandibular opening in conjunction with continued rotation to functional opening = 40 mm
-If translation is severely restricted, 20 to 25 mm of opening can still be achieved by rotation alone
(have to have anterior translation for full mandibular depression)
17
Q
Biomechanics - Protrusion
A
- Accessory movement of bilateral anterior condylar translation
- Anterior translation of mandibular condyles in horizontal plane
18
Q
Biomechanics - Lateral Excursion
A
-Contralateral slide - accessory movement of of anterior translation
-Ipsilateral side - accessory movement of spin
(L lateral excursion limited, R problem, R lateral excursion not limited)
19
Q
Note Capsular or Intracapsular Problems
A
Restrictions: -Translation - primary movement restricted, most difficult to restore -Distraction -Lateral glide (rolling, spinning - never the problem)
20
Q
Biomechanics - Disc relationship to condylar head
A
Initial Opening
-First 10 mm disc remains stationary
-Condyles rotate
Mid to complete opening
-Disc and mandibular condyle translate anteriorly relative to eminence of temporal bone
-Disc pulled into posterior rotation by superior stratum
21
Q
Dental Referral
A
- Written referral
- Diagnosis - specifics
- Imaging
- Precautions
- Dental procedures performed
- Medications prescribed (anti-depressants common)
- Other (HA very common)
22
Q
PT for TMD Examination & Intervention
A
- Client history
- Systems screen - differential diagnosis
- Musculoskeletal examination
- Manual therapy techniques
- Exercises
- Modalities
23
Q
Patient History
A
- Cardinal symptoms related to TMD (according to Steven Kraus): Symptoms located in preauricular area (front of ear) with or without reference into temporal or mandibular areas; Symptoms reproduced, increased, or decreased with functional activities or parafunctional activities of mandible
- Symptoms consist of one or combination of: Pain/discomfort; Joint noises during jaw movements; Limited or difficult jaw movements
- Onset, frequency, duration, & intensity of symptoms determine irritability & progression of disorder
- Document what increases and/or decreases symptoms for reassessment
24
Objective Evaluation
```
Systems screen - differential diagnosis
-Neurological issues
-Cervical spine & upper quarter
-Dental screening
Musculoskeletal examination
-Postural examination: alignment, symmetry
```
25
Differential Diagnosis
- Migraine headaches
- Cervicogenic headaches
- Trigeminal neuralgia
- Temporomandibular dysfunction
- Spine disorder: Postural dysfunction; Facet joint disorder; Intervertebral disc disorder
26
Optimal Posture in Standing
- Postural muscles constantly active
- Optimal line of gravity:
- Through external auditory meatus
- Through the midline of the trunk
- Through the greater trochanter
- Anterior to midline of knee
- Anterior to lateral malleolus
27
Symptoms Associated with Spinal Dysfunction
- Headaches: Tension, Migraines
- Facial pain
- Neck & back pain
- Extremity symptoms: Radicular pain, Numbness & tingling
28
Neck & Orofacial Pain
- Evidence of association between cervical spine, stomatognathic system, & craniofascial pain
- 85% of patients seeking care at an Orofacial Pain Clinic (n=283) had cervical muscle tenderness
- 49% had moderate to severe
- 76% of pts with cervical muscle pain had diagnosis of masticatory myalgia
29
Pain in the Neck
- One adult sample, 54% had neck pain in last 6 months
- Economic costs second only to LBP in worker's comp in US
- 25% of diagnoses among patients receiving outpatient PT
- More prevalent in a sample of people with TMD than in people without TMD
30
Theoretical Basis for the Relationship between Cervical Disorders and Orofacial Pain
- The literature provides a strong rationale for investigating cervical disorders in clinics seeing patients with orofacial pain.
- Convergence of cervical sensory information onto the trigeminal system in the trigeninocervical nucleus.
- Neurophysiologic potentiation between masticatory & cervical muscles.
- Neck pain results in increased parafunction = adverse effects on TMJ.
31
Cycle of Pain and Dysfunction
- Muscular overload, postural strain --> abnormal electrical activity in the muscle --> sustained contraction, muscle tension --> reduced blood flow to and within the muscle --> muscle pain --> abnormal electrical activity in the muscle (loop continues)
- if you don't interrupt at muscle pain: muscle pain --> unbalanced postures --> joint pain --> abnormal joint movement --> muscle pain (loop continues)
32
Physical Therapy Examination
- Joint motion - observations & measurements (ROM)
- Joint loading
- Accessory motions
- Soft tissue: Muscular strength, Muscular flexibility, Palpation (Muscle spasms, trigger points, tenderness)
33
Exam - Mandibular Depression
(Measure with patient in good postural alignment (compare to patient's normal posture))
- Opening in sagittal plane
- Measure between superior & inferior central incisor space
- Functional (ability to eat) = 25 to 30 mm
- Ideal = > or = 40 mm
34
Exam - Lateral Excursion
- Horizontal plane
- Measure from superior central incisor space to inferior central incisor space
- Functional = canine to canine
- Ideal = symmetry, past the canine several mm
35
Exam - Protrusion
- Horizontal plane
- Functional
- -Edge to edge of central incisors
- Ideally
- -Inferior teeth should move past superior teeth by several mm
36
Exam - Palpation
(sitting and supine)
- Masseters
- Temporalis
- Suprahyoid
- Infrahyoid
- Sternocleidomastoids
- Scaleni
- Suboccipitals
- Hyoid
- Trachea
- Joint
37
Exam - Intraoral Musculature - Pterygoids (Lateral)
- Palpate buccal (outside) border of upper molars
- Slide fingers towards mandibular head as far as possible
- Tilt fingers in posterior superior direction & palpate anterior medial pterygoid covering fibers of lateral pterygoid
38
Exam - Intraoral Musculature - Pterygoids (Medial)
- Place index finger below tongue towards angle of mandible
- Other index finger on external mandibular angle
- Intraoral palpating finger examines inferior point of insertion of medial pterygoid
39
Exam - Intraoral Musculature - Occlusion
- Look at teeth & how fit together
| - People do what is necessary to chew food & this affects the joints
40
Exam - Joint Loading - Dynamic Loading & Distraction
- Selective test involving either compression (loading) or distraction
- Unilateral resistance placed between upper & lower third molars
- -Ipsilateral side - distraction of condyle
- -Contalateral side - compression
41
Exam - Joint Loading - Passive Loading
- Muscles relaxed with back teeth slightly apart
- Grasp chin with index finger & thumb
- Apply pressure to mandible posterior superior & to right & left
- Counterforce on back of head
42
Exam - Accessory Motion
- Intraoral distraction
- Intraoral gliding
- Intraoral sliding
- Hyoid swallow
43
Specific Diagnoses
- Inflammatory conditions
- -Capsulitis
- -Synovitis
- Capsular fibrosis
- Osseous mobility conditions
- Articular disc displacement conditions
44
Inflammatory Conditions - Patient Complaints
- Pain/discomfort located in preauricular area
- Pain/discomfort produced, increased, or decreased with functional or parafunctional activities
- Pain on ipsilateral side with back teeth together
- Limited opening
- Pain/discomfort decreased, or at least not aggravated by rest
45
Inflammatory Conditions - Palpation
- Lateral to lateral pole of condyle
- >Palpate lateral pole with back teeth touching
- >Reproduction of symptoms on ipsilateral side indicates capsulitis
- Posterior & lateral to lateral pole
- >Open mandible to 30 mm
- >Palpate condylar head & area
- >Reproduction of symptoms on ipsilateral side indicates capsulitis
- External auditory meatus (EAM)
- >Mandible open
- >Place 5th digit in patient's EAM
- >Apply slight pressure forward
- >Have patient bring back teeth together
- >Reproduction or an increase of symptoms on ipsilateral side indicates synovitis
- >Do not be concerned about any noises
46
Inflammatory Conditions - Dynamic Loading & Distraction
- Patient bites on unilateral resistance placed between upper & lower third molars
- Ipsilateral side - distraction
- Contralateral side - compression
- Palpate lateral & posterior to lateral pole, if reproduces symptoms = capsulitis
- Palpate EAM - if only test that reproduces symptoms = synovitis
47
Inflammatory Conditions - Passive Loading (retrusive compression)
- Muscles relaxed with back teeth apart
- Grasp patient's chin with index finger & thumb
- Apply pressure to mandible posterosuperior & to right & left
- Counterforce on back of patient's head
- Reproduction or increase of symptoms suggests either capsulitis or synovitis
48
Inflammatory Conditions - Mandibular Dynamics
- Not reliable for inflammatory conditions
| - May appear normal
49
Capsular Fibrosis - Patient Complaints
(usually direct result of chronic capsulitis)
- Patient history is key to diagnosis
- Usually painless unless force is used during mandibular dynamics to cause injury or overextension of capsule
- Long-term history of capsulitis
- Prolonged immobilization
- Trauma
- Arthritis
50
Capsular Fibrosis - Physical Exam
- Osteokinematic movements limited or altered
| - Suggests decrease in arthrokinematic movement of translation on involved side
51
Osseous Mobility Conditions - Hypermobility
- Usually asymptomatic
- Occurs frequently in patient & non-patient population
- Hypermobility scale
52
Osseous Mobility Conditions - Hypermobility - Patient Complaints
- Subjective statement
- -"My jaw feels like it goes out of place."
- Noted with eating thick sandwich or yawning
- Report of joint noises
- Short term episodes of jaw catching in fully opened position - prevents closure of mouth
53
Osseous Mobility Conditions - Hypermobility - Physical Exam
- Examine while patient performs active mandibular depression
- Palpate lateral pole
- -Reveals larger than expected indentation posterior with excessive anterior movement
- Deflection of mandible towards contralateral side of involved joint at end of opening with unilateral hypermobility
54
Osseous Mobility Conditions - Hypermobility - Physical Examination
- Palpable irregularities at end of mandibular depression & beginning of mandibular closure
- -These are joint noises
- -May or may not be able to hear noises, but can be felt
- Mandibular depression > 40 mm
55
Osseous Mobility Conditions - Dislocation
- History & clinical findings are same as hypermobility
- May not be painful
- Patient presentation
- >Mouth fully open
- >Mouth deflected towards contralateral side of involved joint
- >Inability to close mouth
- Condyle & disc have translated well beyond articular crest onto tubercle & are stuck
56
Articular Disc Displacement Conditions - Disc Displacement with Reduction (DDWR) - Patient Symptoms
- Joint noise during mandibular opening & closing
- Two "pops" or "clicks"
- >One on opening
- >Second on closing
57
Articular Disc Displacement Conditions - DDWR - Physical Exam
- reciprocal click
- Palpation over lateral poles reveals opening click (reduction of disc) & closing click (disc displacing anterior to condyle)
- Reciprocal click occurring at different mandibular positions
- Opening noise loudest, closing noise softest
- Clinician places fingertips under angle of mandible bilaterally & lifts anterosuperiorly as patient opens & closes mandible
- >Preload joint to enhance loudness of reciprocal click, especially closing click
- >Loading joint during movement often will increase or reproduce pain if related to DDWR
- Have patient open to produce opening click, then close forward bringing upper & lower anterior central incisors together end-to-end
- >From forward position, have patient open & close as wide as possible
- >Palpate over lateral poles
- >Large percentage reciprocal clicks with cease to exist
58
**Note - Reciprocal Click**
- If a reciprocal click is not present, a DDWR is not present
- No need to proceed to next 2 tests
- Purpose of these tests is to confirm that reciprocal click is related to a DDWR
59
Articular Disc Displacement Conditions - Disc Displacement without Reduction (DDWoR) - acute - Patient Symptoms
- Used have joint noises & previous episodes of intermittent locking
- Joint noises have ceased
- Inability to open mouth wide
- Difficulty performing functional jaw movements
- >Chewing, talking, yawning
60
Articular Disc Displacement Conditions - DDWoR - acute - Physical Exam
- Mandibular dynamics
- >Depression
- --->Opening limited to 20 to 25 mm
- --->Deflection toward ipsilateral side
- >Protrusion
- --->Limited
- --->Deflection toward ipsilateral side
- >Lateral excursion
- --->Limited toward contralateral side
- No palpable irregularities noted with DDWoR
61
Articular Disc Displacement Conditions - DDWoR - chronic - Patient Symptoms
- History similar to DDWoR
- Progressed to DDWoR
- No limitation in jaw movements
- Describes hearing noises
- >Crepitus with jaw movements
62
Articular Disc Displacement Conditions - DDWoR - chronic - Physical Exam
- Mandibular Dynamics
- >Depression
- --->Functional or close to functional
- --->Minimal deflection toward ipsilateral side toward end of opening
- >Protrusion
- --->Functional or close to functional
- --->Minimal deflection toward ipsilateral side toward end of protrusion
- >Lateral excursion
- --->Functional or close to functional toward contralateral side
- >Palpation
- --->Irregularities of crepitus
63
Physical Therapy Intervention - Key
- Key - restore function
- Restore rest position of joint
- >Rocabado 6X6 exercises
- --->Tip of tongue on roof of mouth just behind upper teeth, muscles relaxed, teeth apart
- --->Chest out - pulls head back
- --->Upper cervical flexion 15 degrees - straightens cervical spine, more may cause discogenic problem in cervical spine
- --->Diaphragmatic breathing
64
PT Intervention - Patient Education
- Rest joint, if inflamed must allow inflammation to calm down
- Soft diet
- Minimal chewing - no gum
- No heavy kissing
- No wide opening - large sandwich, apple
- Nasal breathing
- Yawning
- Sleep supine
- No caffeine
- No tobacco
65
PT Intervention - What to Address?
- Address posture
- >Forward head posture
- >Headaches
- Address soft tissue
- >Flexibility of upper quarter
- >Muscle imbalance - strength
- >Muscle spasms and guarding
- >Capsular tightness
- >Scar tissue
- >Motor control
66
PT Interventions
- Posture correction
- >Stretch tight structures
- >Strengthen weak structures
- Manual therapy
- >Soft tissue mobilization
- --->Anterior & posterior neck
- --->Upper quarter
- >C-spine mobilization
- Aerobic exercise
67
PT Interventions - TM Manual Intraoral Techniques
- Used to restore functional mandibular dynamics regardless of disc position
- Combination of distraction or translation
- Distraction - acute DDWoR or capsular fibrosis
- Distraction with translation
- Lateral glide - capsular fibrosis
68
PT Interventions - Modalities
- Ultrasound
- >Intensity 0.5 w/cm^2, pulsed, 3.3 MHz, 5 minutes with patient pumping/flushing joint to nourish it
- Ice
- Iontophoresis
69
PT Interventions - Caution
Temporomandibular techniques
- Use caution - joint swells easily
- More is not always better ... sometimes its just more.
70
PT Interventions - HEP
- HEP
- >Instruct patient to do exercises at home
- Address cervical spine & upper quarter
71
Intervention - Oral Appliances
- Upper & lower appliances
- Dentist fabricates & adjusts appliances
- Used to address teeth
- Physical therapist facilitates soft tissue adaptation
72
Surgery
- Performed by oral surgeon specializing in TMD
- PT encourage early referral post-operatively
- Arthrocentesis
- Arthroscopy
- Arthrotomy - open joint
- Menisectomy and/or condylectomy
- Temporomandibular implants
73
Big Picture
- Interdisciplinary teamwork
| - >Dentists & physical therapists working together achieve the best functional outcomes for clients with TMD
Ortho 3
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Decks in class (4)
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