Download TEMPOROMANDIBULAR JOINT DYSFUNCTION

TEMPOROMANDIBULAR
JOINT DYSFUNCTION
Steve Churchill, MPT, LATC, CSCS
AIM Physical Therapy Clinic, LLC
Objectives
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Discuss the basic anatomy and joint
function of the craniomandibular system.
Describe joint motion and associated
muscle function of the temporomandibular
joint.
Describe the importance of postural
positioning and its relationship to TMJ
functioning.
Explain the effects of TMJ hypermobility and
its impact on jaw function.
Introduction
TMJ pain first identified as source of
facial pain in 1934 (COSTEN).
 1960-1970’s TMJ pain thought to be
mostly a dental problem not a joint
problem.
 1980’s TMJ pain thought to be rooted in
muscle dysfunction (Myogenic).
 1990’s TMJ pain thought to be both
muscular and dental related with a
psychological component.
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Today
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TMJ pain is classified as Temporomandibular
Dysfunction (TMD) and continues to be a
controversial diagnosis.
The treatment emphasizes function while
minimizing pain and promoting selfmanagement.
Conservative management or minimally
invasive treatments exhausted prior to the use
invasive procedures.
Introduction
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Prevalence as high as 12% of population have
signs of TMD but many are asymptomatic.
2:1 female to male.
Mean age of onset 30 years of age.
30-40% report joint clicking.
Usually insidious onset but often can find some
history of trauma.
Usually parafunction noted. (microtrauma)
Tension headaches seen in 50% cases.
Treatment
Physical Therapy
 Dentistry
 Pharmacologic
 Surgical
 Psychological
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Temporomandibular Joint
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Complex synovial joint with two convex
surfaces articulating during movement.
Articular disc allows for a more congruent and
stable joint.
Formed by the condyle of the mandible and
fossa-eminence on the temporal bone.
Joint divided into two compartments the inferior
and superior compartments.
The Joint
Inferior Compartment
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Composed of the mandibular condyle and
synovium attached to the distal aspect of the
disc.
Joint capsule is taut in the inferior compartment
to allow for pure rotation of the condyle in the
fossa.
Initial motion of jaw opening occurs in the
inferior compartment as pure rotation.
Superior Compartment
Composed of the temporal
fossa/eminence and the superior
synovium attached to the disc.
 Joint capsule is loose in the superior
compartment to allow for translation.
 Translation of the condyle on the
eminence occurs after rotation.
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Compartments
Ligamentous Structures
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Posterior ligament limits extreme opening and
provides protection for blood and nerve supply.
Anterior capsule provides stability by attaching to
anterior aspect of disc.
Medial and lateral ligaments including the
collaterals attach the disc to the condyle while the
temporomandibular ligament protects the superior
joint structures and assists in condylar translation
while protecting at maximum opening.
Stylomandibular and sphenomandibular limit at
extreme opening.
Muscles of Mastication
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Temporalis guides biting motion to close the
jaw and laterally deviates jaw.
Lateral pterygoid depresses and protrudes the
mandible and guides disc movement by pulling
the condyle and disc forward.
Medial pterygoid elevates or closes jaw.
Masseter initiates elevation of mandible and is
considered the strongest elevator of the jaw.
Digastric muscles pull or depress the mandible
inferiorly.
Hyoids initiate jaw opening.
Craniomandibular System
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Components include the cranio-cervical joints
and craniomandibular joints.
Neck and jaw position need to be evaluated
together when considering facial pain.
Cervical spine positioning and muscle tightness
effect jaw mechanics and vice versa.
Most important area of examination in the
cervical spine is the suboccipital region
including C2.
Neck pain experienced in up to 70% of TMD
cases reported.
Mechanical Entrapment
Neuropathy
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Created by posterior rotation of cranium and
loss of cervical lordosis.
Creates muscle tension and tissue entrapment.
Less than 20 mm of space noted between
occiput and C2 (2 fingers in width).
Changes jaw positioning by causing mandibular
retraction and distal occlusion.
This creates muscle overuse and tension,
thereby changing jaw mechanics.
TMJ Osteokinematics
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Depression(opening)
Lateral excursion
Protrusion
There is a 4:1:1 relationship between opening,
lateral excursion, and protrusion.
Norms for opening approximate 40mm with
lateral excursion and protrusion 10mm but this
varies depending on the source.
Quick reference is 3 fingers width to the PIP.
Joint Arthrokinematics
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The first half of opening occurs primarily as
rotation (roll-glide). 10-20mm
The condyle glides anterior as the disc moves
posterior relative to the joint.
As the temporomandibular ligament tightens
rotation ends and translation begins.
The condyle and disc move forward together
on the eminence to create translation from
20mm of opening and beyond.
Jaw Parafunction
Clenching
 Grinding
 Nail biting
 Excessive tension
 Repetitive overuse
 Jaw compression
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TMJ Hypermobility
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Thought to result from excessive or premature
translation of condyle.
Parafunction causes microtrauma to the disc and
ligamentous tissue.
Mouth breathing leads to an increase in muscle
activity and changes jaw positioning.
Hypermobility creates anterior disc migration and
possible synovium trauma.
Ultimately a vicious cycle is created.
Almost 80% of those with TMJ hypermobility and
parafunction will develop problems versus only 16%
for those that have hypermobility alone.
Signs and Symptoms
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Jaw clicking
Headaches
Facial pain
Jaw locking
Ear pressure
Ear pain
Ear ringing
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Tooth sensitivity
Muscle tension
Malocclusion
Jaw deviation
Neck pain
Suboccipital
tenderness
Disc Displacement
(Internal Derangement)
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Phase 1 involves no joint clicking or significant
pain, but may find disc slightly anterior on
eminence.
Phase 2 involves joint clicking at ten to twenty
mm of opening.
Phase 3 involves joint clicking at twenty to thirty
mm of opening.
Phase 4 involves a loss of 50% of normal
opening with the absence of joint clicking.
Moffett’s Classification
Stage I Disc displacement with reduction.
Joint noise with open & close.
 Stage II Disc displacement without
reduction. No joint noise.
 Stage III Disc displacement with
osteoarthritis. Crepitus present.
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Pain Map
#1
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 #4
 #5
 #6
 #7
 #8
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Anterior - inferior synovium
Anterior - superior synovium
Lateral collateral ligament
Temporomandibular ligament
Posterior - inferior synovium
Posterior - superior synovium
Bilaminar zone
Retrodisc zone
Pain Map
Pain Map Findings
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Map findings guide the exam and treatment.
Pain #1 usually occurs early in dysfunction.
Pain #4 usually due to malocclusion.
Pain #5 indicates start of disc displacement.
Pain #7 start of degenerative process.
Pain #8 posterior joint compression.
Evaluation
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Facial symmetry
Lip position (upper covers 3/4 upper teeth)
Bite position (contact anterior vs posterior)
Profile with head and jaw position
Craniovertebral position
Neck ROM
Jaw ROM and mechanics (quality vs. quantity)
Deviation or Deflection
Muscle palpation
TMJ palpation and pain map
Treatment
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Education
Proprioceptive training
Postural correction
Manual therapy
Relaxation training
Stabilization exercises
Flexibility and ROM
Modality management
Proprioceptive Training
Rest positioning – The tip of the tongue
resting gently against the roof of the
mouth at rest.
 Controlled opening – Proprioceptive
feedback from the tongue to stabilize for
pure rotation in the joint.
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Manual Therapy
Soft tissue mobilization.
 Joint glides.
 Long axis distraction.
 Manual stabilization training.
 Cervical spine mobilization and postural
correction.
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Modalities
Ultrasound
 Phonophoresis
 Iontophoresis
 Electrical Stimulation (TENS)
 Low-Level Laser
 Biofeedback
 Hot and Cold Therapy
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In Summary…
Consider the head and neck position.
 Palpation of the joint and related
musculature.
 Headaches.
 Joint noise.
 Ear pressure or pain.
 Hypermobility.
 Hypomobility.
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Questions?