Download Temporomandibular Disorders (TMD) & Facial Pain

A Clinical View
 Module 1 
By Todd Henkelmann, PT, MS, CCTT
UPMC Centers for Rehab Services
Introductory Remarks

 Today’s lecture and demonstrations will be primarily
about the basics. Plan to pair up at times!
 [Suggest to bring with you: vinyl/non-latex
disposable gloves, small tape measure]
 What questions would you like answered?
 If you delve deeper into the problem of TMD, you’ll
discover a very complex and controversial disorder
and perhaps the best way to approach it is K.I.S.S.
 A good place to start is the AAOP – aaop.org
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What’s in a Name?

 “I’ve got TMJ” – Yes, you have two, one on each
side…
 TMJ Disorder = TMD
 Orofacial Pain = OFP
 American Academy of Orofacial Pain
 Craniofacial Pain = CFP
 American Academy of Craniofacial Pain
 Craniomandibular Disorder = CMD
 European Academy of Craniomandibular Disorders
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Conservative treatment
of TMD

 This is our role as physical therapists; why you can
successfully work in conjunction with dentists and
oral surgeons, have a successful niche practice
 We need to not let 3rd party private payers prevent
treatment of this devastating condition
 Medicare & Medicaid cover it’s treatment
 The TMJ Association – www.tmj.org, Terrie Cowley,
President
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Functional Anatomy
Stomatognathic system

Bony structures
 Temporal bone: mandibular fossa, external auditory
meatus, articular eminence (a.k.a. tubercle), mastoid
& styloid processes
 Mandible: condyle (head of the mandible), neck,
coronoid process, ramus, angle, and body
 Zygoma, teeth
 Hyoid bone
 Upper cervical spine
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Joint Classification:
TMJ

 A synovial, condylar joint of 2 types:
 Ginglymus (hinge) – 0 to 25mm (+/- 2-3) for rotation
 Arthrodial (gliding) - 25-50mm for translation
 As a synovial joint, it has a joint capsule and synovial
fluid. The bony surfaces are covered by fibrocartilage
(not hyaline cartilage…too soft). Fibrocartilage
remodels – why it can heal.
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Joint Capsule and
Ligaments

 Thin, synovial joint capsule, stabilized by the
following ligaments:
 Medial: sphenomandibular lig. – suspends mandible
during wide opening, stylomandibular lig. – acts as a
stop to extreme opening
 Lateral: Lateral (temporomandibular) lig. – prevents
excessive A-P and lateral movements
 TMJ is stabilized primarily by ligaments and convex
on concave relationships above & below by the biconcave articular disc
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The Disc (Meniscus)

 Fibrocartilagenous structure – areas of collagen
fibers, loose connective tissue, blood vessels, and
nerve fibers
 Function of disc is to act as shock absorber,
improve congruency, and enhance joint stability
during movement
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
 Attached to capsule, poles of the condyle via
collateral ligs., and superior belly of lateral
pterygoid muscle. It divides the joint into 2
distinct cavities
 Posterior attachment (also called ‘retrodiscal
tissue’) has a superior (elastic) and inferior
(vascular & neural) stratum that serve to keep
disc from moving too far anteriorly
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Cervical spine

Forward head
posture:
 Loss of cervical lordosis
 Backward bent OA
 Effects orientation of TMJ
 Leads to early DDD and
DJD
 Can cause neural
impingement!
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Neurology

 Trigeminal nerve (CN V) is the principle nerve
supplying the structures of the TMJ
 Ophthalmic branch (V1) – sensory to upper face, eye,
nose, frontal sinuses, dura
 Maxillary branch (V2) – sensory to cheek, upper lip,
lower sinuses, maxillary teeth, dura
 Mandibular branch (V3) – sensory to lower face,
mandibular teeth, chin & jaw (but not angle of jaw
=C2 & C3); motor to muscles of mastication
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Location of C2-C3
dermatomes

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Trigeminocervical nucleus
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
Time for everyone to stand
up and stretch back!
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Overview of TMD
Evaluation

1.
2.
3.
4.
5.
6.
7.
8.
9.
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History
Cervical screen
Posture
Active TMJ ROM
Strength – cervical, mandible
Specific TMJ tests – palpation & loading
Special tests: sensory exam, jaw jerk, facial nerve
Muscle palpation
Outcome measure
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1. History

 When did it start, what were you doing?
 Gradual or sudden onset
 What tests have been done?
 Panorex x-ray, CT scan, MRI – provide “clues”
 Have you suffered a blow to the jaw?
 Volleyball, soccer ball, fist, MVA
 Do you have a click/pop now or in past?
 Was there period of prolonged immobilization?
 Mouth wired shut? Could cause capsular restriction
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
 What makes the pain worse?
 What makes the pain better?
 “What do you do to get any relief?”
 “What can’t you do because of this problem?”
 Have you worn braces and for how long?
 Ask about parafunctional habits
 Start the education process here
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Parafunctional Habits

Clenching teeth (daytime) – teeth touching at rest?
Bruxing at night
Chewing gum, fingernails, ice
Habitually chewing hard-to-chew items
Hand rest on jaw
Holding phone with shoulder against head
Tongue thrusting
High stress level – we all have stress, ask if worse in the past
6 months
 Prone sleep position
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2. Cervical Screen

 Take AROM – Rot, SB, Flex, Ext
 Alar & transverse ligament tests – See next slide
 Spurling’s test
 Cervical compression & distraction tests
 I do not do anything else, unless there is a reason to
 If the patient has radicular symptoms, then you need
to recognize that you’re dealing with 2 different
problems – not part of TMD per se
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3. Posture

 First thing: just observe head, neck & face at rest
 Look for overt asymmetry or swollen area
 Before you say anything about posture, look at
head/neck posture from the side
 Minimal, moderate, severe forward head?
 Are they missing teeth? Does bite come together
evenly?
 Malocclusion vs. unilateral joint effusion vs. unilateral
muscle spasm
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4. AROM of TMJ

 Mandible depression: 0mm to 40-60mm (adult)
 Measure R incisors, unless unavailable
 Side glide (aka, lateral excursion): 0mm to 8mm (I
don’t usually measure)
 Protrusion: 0mm to 6-9mm (I don’t usually measure)
 Retrusion (aka, retraction): Not measured
 Watch for deviation or deflection with depression &
protrusion – can confirm or deny disc displacement
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TMJ Muscle Actions

 Depression (opening): Lateral Pterygoid – inferior
belly, Anterior Digastric, and gravity
 Elevation (closing): Temporalis, Masseter, Medial
Pterygoid
 Lateral Excursion: To Right : R Lat. Pterygoid, L
med. Pterygoid, to Left: L Lat. Pterygoid, R med.
Pterygoid
 Protrusion: Lat. Pterygoids – inferior belly, acting
bilaterally, Med. Pterygoids – indirect
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5. Strength Testing

 Manual muscle tests of:
 Cervical SB, Rot, Flex, Ext
 Mandible SB, Depression, & elevation
 Note: It is not common to see weakness, in my
experience. Roughly 90% of all orofacial pain
patients I see don’t test (+) for weakness. Don’t know
that MMT is the best way to test strength in this
population
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6. Specific TMJ tests

 Force biting test
 Lateral condyle palpation test
 Teeth together, mouth opened
 Retrussive overpressure test
 External auditory meatus test
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7. Special Tests

 Sensory testing - I consider this crucial, yet doctors
and many therapists don’t take the time…
 Test V1, V2, V3, & C2
 Pain sensation, light touch sensation
 Slightly diminished can be caused by mm. spasm,
greater involvement in V2, V3 may mean a tumor
 Jaw Jerk reflex
 Indicative of upper motor neuron condition, but is not
diagnostic
 Facial nerve screen – go through all facial mov’ts.
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8. Muscle Palpation

 Internally: masseter, medial & lateral pterygoids
 Externally: temporalis, digastric,
sternocleidomastoid (SCM), suboccipitals, upper
trapezius
 Others for consideration: zygomaticus, buccinator,
tensor veli palatini, frontalis
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Outcome Measures

 TMD Disability Index Questionnaire (TDI)
 Similar to Oswestry or Neck Disability Index
 Used by Joshua Cleland, et al in research studies (see
bibliography)
 Published by a chiropractor and has not undergone
validation studies
 Scoring method is on last page of handout
 It’s not perfect, but it’s all I have to recommend at this
time
 For Medicare: I am also using AMPAC 4
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Take a Break

 Stand up and stretch backward
 Relax your jaw – were your teeth touching?
 How’s your posture? Are you setting a good
example for your patients? 
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