TMJ (OCS-A summary)

Question 1

The TMJ is divided into what two compartments, by which structure?

Answer 1

• superior and inferior compartments

- fibrocartilaginous disk

Question 2

During opening, the condyle ______ in the _______ cavity, and _______ in the _________ cavity.

Answer 2

• rotates in the inferior compartment

- translates in the superior compartment

Question 3

What are the 3 divisions of the disk?

Answer 3

• anterior
• intermediate (avascular/aneural)
• posterior

Question 4

What muscles are considered depressors?

Answer 4

• suprahyoids
• infrahyoids
• lateral pterygoid (inferior fibers)

Question 5

What muscles are considered elevators?

Answer 5

• masseters
• temporalis
• medial pterygoid
• lateral pterygoid (superior fibers)

Question 6

What muscles are considered protrusors?

Answer 6

• medial pterygoid
• lateral pterygoid
• masseter (superficial fibers)

Question 7

What muscles are considered retractors?

Answer 7

• masseter (deep fibers)
• temporalis
• suprahyoid

Question 8

What muscles are considered lateral deviators?

Answer 8

• medial pterygoid (contralateral)
• lateral pterygoid (contralateral)
• temporalis (ipsilateral)
• masseter (to a lesser degree…)

Question 9

What is considered a normal opening width for the TMJ?

Answer 9

• 3-4 finger widths
• 35 mm is functional
• 40-50 mm is normal

Question 10

What is considered normal lateral deviation?

Answer 10

• 1/4th the amount of opening

- e.g., 10 mm for a 40 mm opening

Question 11

What is considered normal protrusion?

Answer 11

• 6-9mm

Question 12

What is considered normal retrusion?

Answer 12

• 3 mm

Question 13

What are the considerations for classifying internal derangement of the TMJ?

Answer 13

• whether or not the anterior disk reduces or not

Question 14

If a pt experiences a click when the open their jaw, and when they close it, what is this indicative of?

Answer 14

• anterior disk displacement WITH reduction

Question 15

What are often contributing factors to an anterior disk displacement with reduction?

Answer 15

• strong pull of superior lateral pterygoid

- very tight posterior capsule fibers

Question 16

What are the characteristics of an anterior disk displacement without reduction?

Answer 16

• no clicking
• may have limited, painful opening
• if fully displaced, may have normal, but painful opening

Question 17

What is the presentation of a fully displaced anterior disk?

Answer 17

• may have normal opening, but it will be painful

Question 18

What is the presentation of a posterior disk displacement?

Answer 18

• uncommon
• usually occurs after prolonged mouth opening (e.g., dental procedure)
• results in an inability to close the mouth; i.e., open lock

Question 19

What is the open pack position of the TMJ?

Answer 19

• tongue to roof of mouth

Question 20

Is TMJ clicking pathological?

Answer 20

• no, it can be a normal variant

Question 21

Subluxation of the TMJ occurs with over ____mm of opening. Can be associated with connective tissue disorders such as ___________.

Answer 21

• 40 mm

- Ehler’s-Danlos

Question 22

What are the common causes of an ankylosing TMJ?

Answer 22

• trauma
• RA
• polyarthritic disease
• e.g., some type of inflammatory process

Question 23

With an ankylosed side of the TMJ, what will opening look like?

Answer 23

• restricted on the ankylosed side with ipsilateral lateral deviation

Question 24

TMD is associated with what 3 factors/habits/symptoms?

Answer 24

• stress
• headaches
• bruxism
• strong connection between all 4 things

Question 25

T or F; Migraine can be triggered by TMJ tension.

Answer 25

- T

Question 26

What is a pathoanatomical rationale for tension headaches?

Answer 26

- can be caused by postural imbalance w/ forward head posture - posture creates bias for trigeminal and greater occipital n. irritation - results in head/face pain

Question 27

Are cervicogenic headaches usually unilateral or B?

Answer 27

- unilateral

Question 28

Are cervicogenic headaches and TMD commonly associated?

Answer 28

- yes

Question 29

What is a proposed cause of cervicogenic headaches?

Answer 29

- cervical alignment issues; e.g., decreased lordosis

Question 30

What is in the differential with TMD that's not a headache?

Answer 30

- Temporal arteritis

Question 31

What may be a clue for temporal arteritis vs TMD?

Answer 31

- can cause claudication; worsening pain during chewing that follows an ischemic pattern - potential for severe temporal headache - can create visual changes

Question 32

How can one differentiate between a capsular vs disk issue with mouth opening?

Answer 32

- Capsular: deviates from midline, but then returns to midline with full opening. - Disk: deviates from midline and does not return (Deflection)

Question 33

What is the Cotton Roll Test used for? How does it work?

Answer 33

- differentiating muscle vs joint origin of pain - biting down with back molars on cotton roll creates gapping/unloading at ipsilateral TMJ, with contralateral compression - if pt w/ pain on R, bites down with roll on R and pain is alleviated, then likely joint. If aggravated, then likely muscular

Question 34

What is trismus?

Answer 34

- masseter spasm causing acute lock jaw - <25mm opening - occurs with prolonged mouth opening - TTP at masseter

Question 35

What intervention should be considered with myofascial TMD?

Answer 35

- cervical mobs - deep flexor therex - found to improve pain at rest and with chewing, as well as mouth opening tolerance

Question 36

What is considered a core component of initial TMD intervention?

Answer 36

- education to prevent fear/anxiety and reduce risk of progression to chronic condition

Question 37

When is TMJ manipulation indicated?

Answer 37

- acute closed lock - dislocation - done by doctor or dentist under anesthesia

Question 38

What are some primary intervention types for TMJ?

Answer 38

- education - postural modifications - behavioral therapy - cervical mobs - therex

Question 39

What are specific exercises that are appropriate for TMJ?

Answer 39

- depends on presentation but... - deep neck flexor therex - tongue controlled mouth opening - TMJ isometrics

Question 40

What is a key component of TMJ exercises?

Answer 40

- tongue to the roof of the mouth - opening/closing with tongue at roof - gentle isometrics with tongue at roof

Question 41

How is a longitudinal distraction of the TMJ executed?

Answer 41

- pull down in a vertical axis with force directed via the thumbs on the bottom molars

Question 42

Condylar remodeling exercises are typically used with what type of TMD?

Answer 42

- anterior disk displacement with reduction

Question 43

What do condylar remodeling exercises look like?

Answer 43

- rubber tubing between incisors - lateral deviation AWAY (contralateral) to the painful side - can be w/ or w/o bite force during the deviation

Question 44

What are the key components to management of myofascial pain disorder?

Answer 44

- multidisciplinary - behavioral intervention - education

Question 45

What is an appropriate outcome measure for TMD treatment efficacy?

Answer 45

- Health related quality of life

Question 46

What are common comorbidities related to TMD?

Answer 46

- depression - fibromyalgia - chronic fatigue syndrome - IBS - RA - chronic headache

Question 47

What is the Rocabado 6x6 protocol for TMD?

Answer 47

- 6 reps, 6x/day 1. Cluck 2. Tongue to palate with opening 3. Jaw isometrics 4. Upper cervical flexion 5. Cervical extension with retraction 6. Scapular retraction and depression

Question 48

What are 7 conditions in the differential for TMD that are not tension/cervicogenic headache or temporal arteritis?

Answer 48

- dental caries - post herpetic neuralgia - glossopheryngeal neuralgia - trigeminal neuralgia - giant cell arteritis (...kind of temporal arteritis) - maxillary sinusitis - migraine headache

Question 49

The following is characteristic of which differential dx for TMD? - mandibular pain that is worsened by hot/cold food - dull ache - visible tooth decay

Answer 49

- Dental caries | - tooth pain can refer to the mandible

Question 50

The following is characteristic of which differential dx for TMD? - continuous intraoral or extraoral facial pain - continuous pain - can be sharp, burning - aggravated by light touch or eating - recent shingles virus

Answer 50

- post herpetic neuralgia

Question 51

The following is characteristic of which differential dx for TMD? - unilateral - deep pain in ear, tongue, tonsils, or cervical region - episodic, brief intense attacks of shooting electric shock pain - aggravated with swallowing, coughing, palpation of ear

Answer 51

- glossopheryngeal neuralgia

Question 52

The following is characteristic of which differential dx for TMD? - unilateral - deep pain in head/neck region - episodic, brief intense attacks of shooting electric shock pain - can be spontaneous w/o stimulus

Answer 52

- Trigeminal neuralgia

Question 53

The following is characteristic of which differential dx for TMD? - Temporal region jaw pain - sudden onset with continuous pain - usually dull pain, but can be severe - may have diploplia, weight loss, polymyalgia rheumatica, fever, malaise - can result in blindness

Answer 53

- giant cell arteritis

Question 54

The following is characteristic of which differential dx for TMD? - dull unilateral or B upper quadrant facial pain - usually accompanied by nasal discharge or other signs of respiratory infection - TTP at maxillary and frontal sinus

Answer 54

- maxillary sinusitis

Question 55

The following is characteristic of which differential dx for TMD? - temporal or "behind the eye" pain - photophobia, phonophobia, visual aura - normal cranial nerve screen - often throbbing pain

Answer 55

- migraine | - can often be triggered by TMD