TMD

Question 1

TMJ Anatomy

Answer 1

• only synovial joint in the cranium
• mandible condyle is bi-convex
• temporal bone portion is saddle shaped
• meniscus helps stabalize: translates anteriorly during depression of mandible; innervated at periphery; neural and avascular at force bearing zones

Question 2

Digastric, suprahyoid

Answer 2

-depress mandible (infrahyoid stabalizes hyoid bone) initially, then pterygoids depress jaw

Question 3

Left lateral and medial pterygoids

Answer 3

-move mandible lateral and forward to the right

Question 4

Temporalis, masseter, medial pterygoid

Answer 4

-close jaw tightly

Question 5

Buccinator

Answer 5

–approximates lips and compresses cheeks (blowing)

Question 6

Depressor labii inferior

Answer 6

-protrudes lower lip (pouting)

Question 7

Depressor anguli oris and platysma

Answer 7

-draw corner of mouth down

Question 8

Mentalis

Answer 8

-draws tip of chin upward

Question 9

Orbicularis oris

Answer 9

-approximates and compresses lips

Question 10

Zygomatic minor

Answer 10

-protrudes upper lip

Question 11

Levator anguli oris

Answer 11

-lifts upper border of lip on one side without raising lateral angle (snarl)

Question 12

Zygomatic major

Answer 12

-raises lateral angle of mouth (smile)

Question 13

Risorius

Answer 13

-approximates lips and draws tips and draws corners lateral (grimace)

Question 14

Intracapsular TMJ pathology

Answer 14

-infection, RA, OA, gout, metastatic CA, articular disc displacements

Question 15

Extracapsular TMJ pathology

Answer 15

• Myofascial pain of masticatory muscles
• TMJ myofascial pain syndrome, TMJ dysfunction syndrome, TMJ syndrome
• TMJD: temporomandibular muscle and joint disorder

Question 16

TMJ trauma

Answer 16

• direct or by whiplash injury

- if direct blow with closed mouth, posterior capsule injury

Question 17

TMJ malocclusions

Answer 17

-deviation from normal contact of maxiallary and mandibular teeth

Question 18

TMJ malocclusions class1

Answer 18

-1st molars normal, problem elsewhere

Question 19

TMJ malocclusions class 2a

Answer 19

• lower 1st molar posterior to upper

- mandibular retrusion (overbite)

Question 20

TMJ maloccusions class 2b

Answer 20

-lower 1st molar posterior to upper to greater degree (larger overbite)

Question 21

TMJ maloccusions class 3

Answer 21

lower 1st molar anterior to upper mandibular protrusion (underbite)

Question 22

TMJ muscle strain

Answer 22

• oral habits (tobacco, gum, etc)
• postural/work related (singers, phone operators, musicians)
• sports (trauma, mouthguards)

Question 23

TMJ musculoskeletal problems

Answer 23

• developmental abnormalities–condylar hypoplasia/agenesis

- somatic dysfunction–temporal bone dysfunction; compensatory changes (short leg syndrome, scoliosis, etc)

Question 24

TMJ Mood disorders

Answer 24

-anxiety, depression, post-traumatic stress disorder, history of abuse
some studies show association between chronic TMD and above disorders

Question 25

TMJ and RA

Answer 25

-more likely to develop TM pain

Question 26

Unilateral TMJ problem symptoms

Answer 26

- cephalgia--misdiagnosed as migraines - otalgia - neck pain - eye pain - shoulder and back pain

Question 27

Most common signs and symptoms of TMD

Answer 27

- pain, ear discomfort or dysfunction, headache, TMJ discomfort - patient may complain of cephalgia, and mention jaw problems or not mention jaw problems - may describe as a dull ache that is worse with chewing - tinnitus

Question 28

More TMD symptoms

Answer 28

- difficulty opening mouth - click, crepitus=jaw click usually present with disc displacement, but by itself non-diagnostic - lateral deviation of jaw - spasm within facial muscles - onset of symptoms may correspond with onset of stress - neck pain--trauma, bad posture, and musculoskeletal tension nine cervical area - eye pain--orbital/perioribital pain ofen described as unilateral, constant, and boring - arm/back pain--shoulder pain that radiates down arm +/- tingling or numbness - dizziness associated with ear pain and stuffiness or cervical muscle strain and tension

Question 29

Jaw clenching

Answer 29

- often due to anxiety and psychosocial stress - does not interfere with treatment in most cases, although a severely disturbed capacity for interpersonal relationships associated with poor prognosis

Question 30

Types of TMJ dysfunction

Answer 30

- opening click - closing click (reciprocal clicking) - inability to fully open jaw (close locked) - inability to close--if bilateral - crepitus and grating - fusion of the joint (ankylossis)

Question 31

Causes of TMJ click

Answer 31

- almost always due to disc displacement--after disc thin/stretched - adhesions - uncoorditated muscle action of pterygoids - tear or perforation of disc - osteoarthritis--more likely to have crepitus - occlusional imbalance--less likely

Question 32

TMD history

Answer 32

- most often complains of facial pain, headache, ear symptoms, TMJ pain, or symptoms of jaw dysfunction - ask about history of jaw trauma, sleep habits/position, symptoms of nightime bruxism (jaw sore or HA in AM) - past/present use mouth orthotics - ask about occupation/hobbies; personal habits: usual posture, nail biting, or frequent gum chewing; symptoms of depression or anxiety; any recent stressful event - include usual ROS: fever/chills/weight loss/PMH etc

Question 33

TMJ evaluation

Answer 33

- osteopathic exam (not just cranial bones) - complete evaluation, being especially careful to note symmetry/asymmetry-C spine; leg lengths - palpate joints for crepitans/clicks - palpate muscles of mastication - ROM - not facial asymmetry - observe for cavities; suspicious lesions in mouth; alignment of teeth

Question 34

PE findings with compelling signs of TMD

Answer 34

- abnormal mandibular movements | - decreased ROM of TMJ--normal functional opening is 35-55 mm; functional opening in TMD usually

Question 35

Disc displacement

Answer 35

- symptoms of TMJD: MRI showed displaced disc in 84% of patients - no symptoms of TMJD: 33% had displaced disc

Question 36

TMD differential diagnosis

Answer 36

- inflammatory disease: local infection, RA, giant cell arteritis - dental problems: loss of posterior teeth support - Lymphoproliferative disorders - migraine related disorders--carotodynia - Eagle's syndrome (stylohyoid syndrome)--elongated styloid process - Neurlagias: trigeminal, glossopharygeal - parotid gland disorders

Question 37

TMD treatment

Answer 37

- nonpharmacologic: pt education; self-care aimed at improving pain and function (change head posture, sleeping position, and aggravated parafunctional oral behaviors - patients usually respond to these noninvasive conservative treatments - find cause and treat - eliminate jaw stress: bite plate appliance to decrease nocturnal bruxism/jaw clenching; dental care; decrease chewing - correct structural imbalances - heat for muscle spasms - jaw exercises - decrease stress - TENS unit - biofeedback, relaxation techniques, habit reversal - work with dentist - oral devices/occlusal splints

Question 38

TMD medication

Answer 38

- muscle relaxants, TCAs--give at nighttime; continue 1 month until pain is gone - NSAIDS/analgesics usually not adequate - narcotics not indicated unless severe trauma - intraarticular steroids (once) - botulinum toxin injections

Question 39

TMD surgical correction

Answer 39

- last resort! - TMJ prosthetic--attaches to mandible and skull - consider if inflammatory arthritis involving TMJ, recurrent fibrosis, bony - ankylosis, trauma, developmental abnormality, or pathologic lesion