TMJ

Question 1

Capsulitis/synovitis

Answer 1

• TTP at TMJ lateral condyle or posterior compartment
• Pain with biting on opposite side
• Pain with retrusion overpressure
• Pain with accessory motion testing

Question 2

Capsular Fibrosis

Answer 2

• limited AROM with mandibular dynamics
• Limited mobility with TMJ accessory motion tests
• No joint sounds
• Deviation of mandible with opening toward limited side
• History of trauma or surgery
• Dr B: chronic inflammation, trauma, immobilization, entrapped disc

Question 3

Masticatory Muscle Disorders

Answer 3

• No joint sounds
• Pain with palpation of muscles of mastication
• Inconsistent alterations in mandibular control
• Parafunctional oral behavior
• Pain with biting on same side of facial pain
• Commonly tendonitis of temporalis, overuse

Question 4

Hypermobility

Answer 4

• Excessive AROM with opening >40mm
• Joint sound at end range of opening
• Hypermobility with accessory motion testing
• Dr B: can be asymptomatic, collateralls loosen, hypothesized pre-cursor to disc displacement

Question 5

Anterior Disc Displacement with Reduction

Answer 5

• Reciprocal joint sound with opening/closing
• S curve with opening
• Full AROM (unless combined with capsulitis)
• Dr. B: laxity in collaterals and retrodiscal lamina

Question 6

Anterior Disc Displacement without Reduction

Answer 6

• History of joint sounds
• Limited opening <25mm if acute
• Deviation of mandible with opening toward limited side

Question 7

Osteoarthritis

Answer 7

• TMJ crepitus as noted with stethoscope
• Pain with TMJ palpation
• Radiographic evidence of osteoarthritis

Question 8

Movements of Mandible

Answer 8

• Elevation/Depression
• Protraction/Retraction
• Lateral gliding
• Combinations of above

Question 9

TMJ Ligaments

Answer 9

• Medial Collateral
• Lateral Collateral
• Fibrocartlaginous Disc

Question 10

Muscles in lateral excursion

Answer 10

• ipsalateral temporalis, massester

- contralateral medial/lateral pterygoid

Question 11

FHP =

Answer 11

posterior occlusion

Question 12

Retracted C-spine =

Answer 12

anterior occlusion

Question 13

FHP Links (2)

Answer 13

• Increased passive tension of suprahyoids, infrahyoids

- Pulls mandible inferiorly, posteriorly

Question 14

Early phase opening

Answer 14

• First 35-50% of ROM (first 20-25 mm)
• Rotation in inferior joint space
• Increased tension in oblique portion of lateral lig

Question 15

Late phase opening

Answer 15

• Last 50-65% of ROM (last 20-25mm)
• Anterior translation in superior joint space
• Increased tension in sup. retrodiscal lamina

Question 16

Early phase closing

Answer 16

• Posterior translation in superior joint space
• Disc pulled back by tension in superior retrodiscal lamina, posterior fibers of temporalis
• Controlled by eccentric superior lateral pterygoid

Question 17

Late Phase closing

Answer 17

• Rotation in inferior joint space

- muscles of mastication (temporalis, masseter, medial pterygoid)

Question 18

Subjective

Answer 18

• onset of symptoms
• Incidence of jt locking– open or close
• Presence of jt sounds (jt click hallmark of disc derangement, click on opening/closing)
• History of surgery/trauma
• Pain (intensity, frequency, location)
• Outcome measure (TM disorder disability index)

Question 19

Capsulitis/Synovitis – Rx

Answer 19

• Ionto (dex or xylocane)
• Manual therapy – intraoral STM, non-thrust mobs
• Postural and TMJ proprioception ex

Question 20

Capsular Fibrosis – Rx

Answer 20

• Heat
• TMJ mob/manip, prolonged stretching
• AROM, proprioception exercises

Question 21

Disorders of Muscles of Mastication – Rx

Answer 21

• Heat
• Controlled opening/closing muscle re-ed
• intraoral and extraoral STM
• Pt ed, activity mod (gum chewing, grinding)

Question 22

Hypermobility – Rx

Answer 22

• avoid end-range positions (tongue on roof of mouth when yawning, avoid taking large bites)
• Exercise: proprioception, stabilization

Question 23

Articular Disc Displacement with Reduction – Rx

Answer 23

• TMJ mob
• STM
• Posture ROM, isometric stabilization exercises
• Splints

Question 24

Disc Displacement without Reduction – Rx

Answer 24

• TMJ mobs
• Cspine mob/manip
• Posture, Cspine exercises
• Pt ed (soft foods, parafunctional habits, tongue resting position, relaxation, activity modification)

Question 25

TMJ OA -- Rx

Answer 25

- TMJ joint mobs - AROM/PROM - STM - Postural exercises

Question 26

Rocabado's 6x6

Answer 26

- 6 exercises, 6 reps each, 6x/day 1. Tongue rest & nasal breathing 2. Controlled opening 3. Rhythmic stabilization 4. Craniocervical flexion 5. Cervical retraction 6. Shoulder retraction

Question 27

Proprioception training

Answer 27

- Phase 1 (ROM phase): Perform active lateral deviation away from painful TMJ within pain free ROM and without jt sounds - Phase 2 (Bite phase): At end of lateral deviation ROM, pt applies submaximal bite onto tube, holds 5 sec. Mandible then back to midline. 5-6 reps - Phase 3: maintain bite as mandible is returned to midline - Phases 4-6: Protrusion ROM, bite at end range, and bite as return to starting postion -- progress like phase 2/3 - Final progression: gently pull tube and resist in either protrusion or laterally deviated position

Question 28

ROM exercises

Answer 28

1. To increase lateral excursion/protrusion -- place tongue blades between teeth for ~10-11mm opening. Pt then protrudes mandible at this opening or protrudes and glides 2. pt actively opens mouth, finger pressure is applied to the maxillary and mandibular directions with one or both hands

Question 29

Isometric Stabilization

Answer 29

- first one, then two knuckles placed between teeth, then removed, keeping teeth apart, Apply gentle pressure to lower jaw - builds on exercises in Patient-Related instruction

Question 30

Hypermobility and Muscle Performance

Answer 30

- TMJ rotation/translation control - proprioception, strengthening, and stabilization ex - isometric or static exercises initially - progress to dynamic/functional