Download The Temporomandibular Joint

Chapter 23
The Temporomandibular Joint
Copyright 2005 Lippincott Williams & Wilkins
Anatomy and Kinesiology
 Bones of skull, mandible, maxilla, hyoid, clavicle,
sternum, shoulder girdle, and cervical vertebrae
 TMJ and dentoalveolar joints (e.g., joints of teeth)
 Cervical spine
 Muscles and soft tissues of head and neck and muscles
of cheeks, lips, and tongue
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Stomatognathic System
Teeth
Muscles
Joints
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Bones
 Mandible – Ramus and
two condyles.
 Temporal bone – Articular
tubercle, eminence,
mandibular fossa,
posterior glenoid spine
 Hyoid bone.
Movements of Mandible
 Elevation
 Depression
 Protraction
 Retraction
 Lateral gliding
 Combinations of above
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TMJ – 2 Joints
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Muscles
Temporalis
Masseter
Medial pterygoid
Lateral pterygoid
Digastric
Mylohyoid
Genohyoid
Omohyoid
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Muscles
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Tongue
Genioglossus is main muscle responsible for
positioning of tongue.
Active in protracting and elevating tongue.
Anterior open bite, airway compromise, etc. are
indicative of parafunctional habits (tongue thrust,
etc.).
Tongue position/habits will also influence
cervical spine.
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Kinetics


TMJ, teeth, and cervical spine are intimately related.
Cervical posture affects mandibular path of closure.

1.
2.
Forward Head Posture (FHP) – 2 types
With posterior cranial rotation (PCR)
Without posterior cranial rotation
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FHP – With PCR and Without PCR
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Examination and Evaluation
Subjective
Onset of symptoms
Incidence of joint
locking
Presence of joint
noise
History of surgery
Pain (intensity,
frequency, location)
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Pain Examination (Palpation)
Tenderness, Warmth, and Inflammation
Mandible, hyoid, TMJ
Relevant joints of upper quadrant, cervical, and
upper thoracic spine
Muscles
Relevant trigger points and tender points of
fibromyalgia
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Mobility Impairment Examination
Active and passive physiologic ROM of
cervical and thoracic spine
TMJ: A/PROM – Vertical opening, lateral
excursion, protrusion
Joint function (TMJ translation and rotation)
Muscle tests (length, test, control)
Mobility of nervous system (if indicated)
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ROM Exercises
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Therapeutic Exercise for Common
Physiologic Impairments
Hypomobility
 Limitation of functional movements.
 May result from disorders of mandible or cranial bone (dysplasia,
hypoplasia, etc.).
Treatment
 US + stretching or AROM to increase extensibility of tissues.
 Self-stretch exercises.
 Post isometric relaxation (PIR) techniques.
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Hypermobility
Heat and ice if condition is painful.
Muscle Performance
TMJ rotation and translation control.
Strengthening and stabilization exercises.
Isometric or static exercises.
Dynamic exercises.
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Isometric Stabilization
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Posture and Movement Impairments
 FHP with rounding of shoulders and TMJ
signs/symptoms.
Treatment
 Neuromuscular relaxation training.
 Head, neck, and shoulder postural training.
 Mandible and tongue postural exercises.
 Swallow sequence and breathing exercises.
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Therapeutic Exercise Interventions for
Common Diagnoses
Capsulitis and Retrodiskitis
 Inflammation response in fibrous capsule, synovial
membrane, retrodiskal tissues.
Treatment
 Ice, moist heat, massage, US, etc. to reduce pain.
 Joint stabilization splint, anterior repositioning appliance.
 Stretching and PIR techniques.
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DJD/Osteoarthritis
Treatment
AROM exercises
Mobilization techniques
Stretching techniques
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Derangement of the Disk
Anterior Dislocated Disk with Reduction
 Anterior repositioning appliance
 Non-repositioning appliance (flat plane splint)
 Heat, ice
 Education to relax muscles (SEMG feedback to
reduce muscle activity)
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TMJ Clicking
Lower jaw thrust
exercises
Noninvasive isometric
exercises
Mandibular stabilization
exercises
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Anterior Dislocated Disk Without
Reduction
Joint mobilization techniques
(distraction and translation)
Soft tissue mobilization
(myofascial release and
massage)
Therapeutic modalities
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Surgical Procedures
Postoperative Arthroscopic Surgery
 Intraoral joint mobilization techniques
 Active isometric and dynamic exercises
Postarthrotomy Surgery





Massage of temporalis and inferior to masseter
Soft tissue mobilization techniques
Friction massage
Acupressure
Myofascial release or manipulations
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Adjunctive Therapy
Surface Electromyography
Tension recognition/discrimination training
Threshold-based relaxation training
Nocturnal SEMG feedback
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Summary
 Relationships of stomatognathic system requires
a thorough evaluation and integrated treatment
approach.
 FHP affects the position of mandible, tongue,
hyoid, altering rest position, swallowing function,
airway, and muscle balance.
 Proper positioning of the tongue is essential to
maintain ideal resting position of mandible and
promotes normal swallowing function.
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Summary (cont.)
 Hypomobility of TMJ may result from various
conditions. Treatment seeks to reduce
inflammation and pain and to increase function.
 Hypermobility is usually bilateral; however, it
occurs unilaterally when there is a unilateral
restriction.
 Postoperative rehab can be 6–12 months.
Intervention includes reducing inflammation and
begin A/PROM.
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