TMD (Temporal Mandibular Dysfunction)

Question 1

Normal mouth opening

Answer 1

• 40 to 50 millimeters

Question 2

Normal mouth protrusion

Answer 2

• 8 to 10 millimeters

Question 3

Normal lateral excursion

Answer 3

• 8 to 10 millimeters

Question 4

Common signs and symptoms of TMD

Answer 4

• Headaches, frontal, temporal & occipital (cervicogenic)
• Facial pain: masseter, temporalis, TMJ region, neuralgia
• Ear pain: often seen first by ENT
• Pain reported with eating & opening of mouth
• Abnormal movement patterns oof the mandible noted
• Popping & clicking
• Usually coexists with cervical pain & other upper quarter dysfunction

Question 5

Epidemiology of TMD

Answer 5

• Usually females
• 20-50 years old
• Hx of facial head and neck trauma
• Hx oof asymptomatic click from childhood or teen years
• Hx of orthodontics (malocclusion)
• Poor dentition
• Often ectomorphic & hypermobile (Beighton score)
• Referred from DDS, ENT, PCP

Question 6

What muscles help with opening/mandibular depression

Answer 6

• Gravity assisted & digastrics (supra hyoid group)
• Assist later opening by lateral pterygoid upper portion

Question 7

What muscles help with closing

Answer 7

• Masseter
• Temporalis
• Medial pterygoids

Question 8

What muscles help with protrusion

Answer 8

• Bilateral heads of the superior lateral pterygoids & assisted by medial pterygoids

Question 9

What muscles help with retrusion

Answer 9

• Posterior temporalis
• Assisted by deep masseter

Question 10

What muscles help with lateral trusion/deviation

Answer 10

• Contralateral contraction of medial pterygoid & lateral pterygooid
• Ipsilateral temporalis & masseter

Question 11

Describe the osteology of the TMJ

Answer 11

• Mandibular condyle articulates with temporal bone (mandibular fossa) via the disc.
• The disc separated the joint into upper and lower joint compartments
• Articular surfaces are fibrocartilage, not hyaline - fibrocartilage can repair and remodel
• Biconcave disc- superior convex and inferior concave articulating with condyle
• Articular eminence/tubercle anteriorly

Question 12

Describe the disc and capsule

Answer 12

• Disc attached to medial and lateral poles of condyle and posteriorly to superior lamina which is elastic and allows it to stretch
• Retrodiscal tissue: Superior lamina attaches to tympanic plate; Inferior lamina not elastic and attaches to neck of condyle
• B/w 2 lamina is loose connective tissue that is rich in vascular and neural supply-painful when compressed
• Capsule attaches inferiorly to neck of mandibular condyle; laterally and medially to circumference of temporal fossa (above disc is loose and below is tight); very vascular and innervated

Question 13

Describe the biomechanics of the TMJ

Answer 13

• 2 joints in one that is divided by a disc
• Superior joint is larger & each joint has its own synovium
• Superior joint is formed by fossa & superior surface of disc (gliding or anterior translation)
• Inferior joint is formed by condyle & inferior surface oof disc (this is where anterior rotation of condyle under disc occurs)
• Superior lamina allows disc to translate forward along the fossa
• Inferior lamina tethers disc and limits forward translation of condyle

Question 14

Describe the biomechanics of mandibular depression

Answer 14

• Opening: anterior rotation of condyle on lower disc surface (1st 25mm of opening)
• Anterior translation of disc/condyle along the fossa surface (further 25mm)
• Normal opening is 40-50mm

Question 15

Describe the biomechanics of mandibular protrusion & retraction

Answer 15

• All translation occurs in upper joint space
• Coondyle & disc translate together
• Retro discal tissue stretches

Question 16

Describe the biomechanics of lateral deviation to the right

Answer 16

• R condyle rotation & L condyle translation
• Normal ROM is 8-10mm
• 1:4 ratio of lateral deviation to depression

Question 17

Describe a C-Curve

Answer 17

-Capsular pattern of restriction
- Usually no click or pop
- Mandible deviates towards restricted side

Question 18

Describe a S-Curve

Answer 18

• Anterior displacement of disc off condyle
• Anterior translation is blocked until disc reduces itself on condyle during depression
• After reduction of disc then mandible returns to midline
• Usually associated with click or pop

Question 19

Describe deviations

Answer 19

• Lateral movements with return to midline
• The opening pathway is altered but returns to midline
• Usually indicative of a disc displacement with reduction or could be neuromuscular dysfucntion

Question 20

Describe deflections

Answer 20

• Lateral movements without return to midline
• Deflections are usually associated with disc dislocations without reduction or a unilateral muscle restriction

Question 21

Describe the meaning of pops or clicks in the TMJ

Answer 21

• Can be normal
• Hx of parafunctional activity: Bruxism (grinding at night) common
• Auscultation can be used but not necessary
• Opening & closing clicks indicative of disc displacement with reduction

Question 22

What would you look for in a patient’s posture/observe for TMD

Answer 22

• Sitting/standing posture
• Posture rotation of cranium
• Facial symmetry
• Observe with tongue in resting position
• Signs of parafunctional habits: masseter hypertrophy

Question 23

Describe the cervical relationship to TMJ involvement

Answer 23

• Forward head posture (FHP) creates mandible depression, tension & fatigue of anterior supra hyoid muscles, tightening of posterior extensor mm
• Thought to translate mandible superiorly & posteriorly forcing condyle up into fossa contributing to disc dislocation/cumulative tissue trauma

Question 24

Normal TMJ ROM values

Answer 24

- Opening: 40-50mm - Closing: look at mandible position = midline, cross bite, overbite, underbite - Lateral: 8-10mm - Protrusion: 10mm - Retrusion: 5mm

Question 25

Describe the TMJ compression bite test

Answer 25

- Comprised of forceful unilateral biting for 20 sec on a tongue depressor in the first molar region - Familiar pain on the contralateral side to the clenching side is considered a positive test for joint pain & ipsilateral pain is indicative of muscle disorder - Contralateral = joint issue - Ipsilateral = muscle issue - A patient can have both

Question 26

Describe disc displacement with reduction

Answer 26

- Opening & closing clicks (may have 2 clicks on closing) - Disc displacement without reduction is a progression of the former - 1st opening click - 2nd opening click - Locking - 1st closing click - 2nd closing click

Question 27

Describe a near screen for TMD

Answer 27

- Test facial nerve & UE dermatomal scan - UE deep tendon reflexes - Test Trigeminal nerve - Motor testing of mandible, lateral deviation, clenching, & opening

Question 28

Describe disc displacement without reduction

Answer 28

- Disc remains displaced anteriorly blocking anterior rotation & translation for full opening motion - Redistricts movement to ~25mm - No click as disc is stuck in anterior position

Question 29

Describe joint pain

Answer 29

- Dull or sharp pain at the TMJ or inside ear associated with chewing on opposite side, sleeping on same side

Question 30

Describe muscle pain

Answer 30

- Dull ache, anterior to TMJ, at temporal region, associated with same side chewing or clenching with stress

Question 31

List the functional outcome measures for TMD

Answer 31

- TMJ disability index (TDI) - TMJ disability index questionnaire: Steigerwald/Maher - Patient specific functional scale - TSK-TMD (Tampa scale of Kinesiophobia-TMD) if chronic pain is a factor

Question 32

Describe the TMJ classifications

Answer 32

- Group I Masticatroy muscle disorder: Ia = with normal opening; Ib = with limited opening - Group II Disc displacement: IIa = with reduction; IIb = without reduction with limited opening; IIc = without reduction without limited opening - Group III Joint dysfunction: IIIa = arthralgia; IIIb = osteoarthritis; IIIc = osteoarthrosis

Question 33

Describe primary HA Hx

Answer 33

- Migraine - Tension type - Cluster

Question 34

Describe secondary HA

Answer 34

- Medical Hx of HTN, cardiac HX, angina - Systemic: RA, lupus, fibromyalgia, bilateral pain - Cervical posture, DNF strength, ROM, posture, segmental motion, palpation - Dental: Hx, teeth, bite, observation of oral cavity - Ear: Hx, otoscope, pressure over tragus - SinusL sinus pain, nasal congestion, reduced smell, sinus tap test - Eye: acute vision loss, eye pin with eye movement, palpation temporal artery - Cranial neuralgia (CNS)

Question 35

Treatment interventions for TMD

Answer 35

- Education: dietary (softer diet, switch sides when chewing, avoid foods that require big bites), reduce parafunctiional habits (bruxism, lip biting), functional habits (avoid WBing on joint, adapted yawning - block or tongue position), psychological factors, pain science education, & coping strategies - Modalities: Estim, iontophoresis, dry needling, ultrasound (up for discussion) - Therapeutic exercises: Rocabado 6x6 program & Kraus TMD exercises

Question 36

Describe Recabado 6x6 program

Answer 36

- 6 exercises, 6 reps, 6x/day

Question 37

Describe Kraus TMD exercises

Answer 37

- Includes inhibition of excessive masticatory muscle activity - Neuromuscular control - Choose interventions to address pain, joint clicking, muscle asymmetry, deviations in active ROM patterns & spasms that limit opening

Question 38

Lists the different joint mobilizations we can do for TMD

Answer 38

- Distraction - Anterior glides - Unilateral caudal lateral glide (sitting) - Medial/lateral glide - Caudal anterior medial (CAM) - Self mobilization of TMJ for medial glide - Soft tissue mobilization: friction massage, trigger point release (intra/extra oral)