Theory & Methods of Physical Therapy Procedures II
University of Oklahoma Health Sciences Center
Temporomandibular Joint (TMJ): Evaluation and Treatment
Terminology:
Occlusion: "to close", the relationship between the maxillary and mandibular teeth when they are in contact.
Centric Occlusion: ideal maximum contact of the teeth.
Malocclusion: deviation from normal occlusion.
Bruxism: "grinding", forced clenching and grinding of teeth.
Functional Activities: chewing, yawning, swallowing and talking
Para-functional Activities: clenching, bruxism, nail biting, oral breathing, gum or tobacco chewing, lip or cheek chewing, resting jaws in hands, smoking. Typically WIU place more stress on TMJ.
Clinically Relevant Anatomy:
Joint Components:
Mandibular fossa of temporal bone
Condyle of mandible
Interposed biconcave disc. Disc divides the joint into upper and lower compartments.
Joint Classification: Synovial - Ginglymoarthrodial (hinge/planar)
Innervation: Mandibular branch, Trigeminal N. (CN 5)
Close packed position: centric occlusion
Closing loads the joint
Loose packed position: mouth slightly open - 2-6mm
Opening unloads the joint
Overbite: 1-2mm
*Anatomically two joints, Functionally considered one*
Osteokinematics:
Elevation - Depression: Normal opening - 40 mm
Protrusion – Retraction: 3-8mm
Lateral deviation R or L: 8-10mm
Arthokinematics:
Depression: 2 phases - combination of accessory motions of rotation and translation
Phase I:
Rotation (initial 10-15 nun of opening) occurs in the lower compartment, disc remains stationary
Phase II:
Glide or translation (15 to 40 mm opening) occurs in the upper compartment, disc will translate forward
Elevation:
Reverse of depression
Protrusion:
Both condyles/discs translate forward, ROM - 5mm
Retrusion:
Reverse of protrusion, ROM - 3mm
Lateral deviation:
ROM - 8-10mm
Anterior translation on the contralateral side; Spin on the ipsilateral
Primary, Muscles of Mastication
Masseter - action: elevation
Temporalis - action: elevation
Medial Pterygoid - action: Elevation, deviation to contralateral side
Lateral Pterygoid - action: Protrusion (also, superior head pulls disc forward), and deviation to contralateral side. Probably most important muscle to understand.
Primary Muscles of Swallowing
Suprahyoid: TMJ depression and retrusion
ETIOLOGIES
1. Malocclusion
2. Muscular over extension (wide yawn or bite) or over contraction (bruxism, masticator hyperactivity)
3. Psychological component: pts inability cope with stress or anxiety
4. Cervical spine dysfunction, abnormal head and neck posture
5. Usually female - 75%
**Any or all of these may act as an initiating, aggravating, or accelerating variable**
EVALUATION
HISTORY
1. Location of pain: preauricular area, w/wo referral to temporal or mandibular areas
2. What movements cause jaw pain: Opening (extraarticular); Closing (intraarticular)
3. Does occlusion feel "off"? Pain with activity?
4. Do Functional/Parafunctional activities aggravate or alleviate pain
5. Difficulty with activities: i.e.; chewing on one side
6. History of joint noise
7. History of bruxism
8. Oral habits
9. Dental history: dentures, appliances and previous surgeries.
10. Other head, neck, face, ear discomfort
11. Psychological factors
OBSERVATION
1. Facial asymmetry: swelling increased unilateral mm development, mm paralysis
2. Posture: forward head, this will limit opening
3. Teeth: abnormal wear pattern, malocclusion, overbite, crossbite
4. Tongue position: normal resting position is against anterior palate
RANGE OF MOTION: active, passive, resisted
Active: Qualitative opening (40ram), closing (centric occlusion), protrusion (5mm)/retrusion (3mm), lateral deviation R or L (8-10mm)
Qualitative pain/difficulty with movement, deviation with opening, stuttered movements, point in range where popping/clicking occurs
Deflection (S-curve):
Movement of mandible away from the midline during opening.
Returns back to midline by end of ROM.
Indicative of muscle imbalance/incoordination.
Deviation (C-curve):
Movement of mandible from midline during opening.
Does not return to midline.
Indicative of hypomobility.
*Assessment of arthrokinematics is most reliable eval tool for arthrogenous problems*
PALPATION:
Intraoral, extra oral, intraauricular, auscultation.
**Most reliable assessment tool for myogenous problems**
Intraoral:
Lateral pterygoid
Extraoral:
Masseter, temporalis, lateral and posterior joint
Intraauricular:
Posterior components of joint
Auscultation:
Determines location of joint noise
SPECIAL TESTS:
Dynamic Loading (compression)
Unloading (distraction)
Unilateral biting against resistance placed between the molars will distract the ipsilateral side and compress the contralateral side.
Common areas of muscular referral to TMJ:
Masseter, Temporalis, SCM, Upper Trap
ASSESSMENT TMD
INTRAARTICULAR vs EXTRAARTICULAR
MYOGENOUS CONDITIONS (extraarticular)
* aka: Myofascial Pain Dysfunction (MPD), Myalgia, Myositis, Masticatory Muscle Disorders (MMD)*
HX:
Usually unilateral, dull, diffuse pain the tends to radiate to temporal, mandibular, or lateral cervical area
History of bruxism
Temporal HA's
Tenderness
Possible clicking
BEWARE
(most people click & pop)
Feeling of muscle incoordination
Pain (+\-) activity
PE:
Tenderness of masticatory muscles
Lack of tenderness to TMJ
Muscle imbalance/in-coordination with movements (usually opening/closing)
Pain with wide opening/resisted closing
Clicking accompanied by pain/tenderness.
ARTHROGENOUS
INFLAMMATORY CONDITIONS(extraarticular): aka: synovitis, capsulitis
HX:
Pain/discomfort in preauricular area
+/- inability to occlude on involved due to effusion
Opening may be limited secondary to pain on involved side
Symptoms tend to decrease with rest and increase with activity
Feeling of "fullness" in joint.
PE:
Tenderness to palpation
**Extraorally(capsulitis) and Intraauricular(synovitis)**
Dynamic loading positive
Ipsilateral side (capsulitis) or contralateral side (synovitis)
Possibly limited opening on involved side due to loss of translation.
*Prolonged inflammation may lead to Capsular Fibrosis.
Will exhibit deflection from midline towards involved side with opening.*
OSSEOUS MOBILITY CONDITIONS(extraarticular):
aka: TMJ hypermobility
HX:
Crepitus
Episodes of "catching" in fully opened position, preventing easy closure.
PE:
Palpable indentation behind condyle due to excessive anterior translation
Deflection from midline towards uninvolved side
Depression in excess of 40mm
Usually asymptomatic unless accompanied by inflammatory condition
May be accompanied by late opening click and early closing click.
DISLOCATION(intraarticular)
HX: open lock
PE:
a) acute condition, b) pt presents with mouth locked in fully opened position towards uninvolved side and unable to close.
ARTICULAR DISC DISPLACEMENT CONDITIONS(intraarticular)
Disc Displacement with Reduction(DDWR): most common
HX:
Pt describes two "pops/clicks"
May be asymptomatic.
PE:
Classic Reciprocal Click:
Early opening click (0-20mm)
Followed by late closing click (last 5mm).
Disc Displacement without Reduction(DDWOR): aka: closed lock
Acute
HX:
Pt states past history of intermittent crepitus/locking
Inability/difficulty to fully open.
PE:
Opening limited to 20-25mm
Deflection towards involved side.
Chronic
HX:
Progression from DDWR to acute DDWOR to chronic DDWOR
No longer feels joint limitation
Increased crepitus.
PE:
Near normal opening
Slight deflection towards involved side at EROM
ARTHRITIDES(intraarticular):
aka: osteoarthritis, DJD, arthritis
HX:
Similar to inflammatory conditions
PE:
Palpable evidence crepitus throughout range
Radiographic evidence bony change
Near normal opening with slight deflection towards involved side.
TREATMENT:
*Assess/Treat the Cervical Spine may be the major source of symptoms*
Soft tissue mobilization:
Massage
Treatment of trigger points primarily in the masseter, temporalis, and lateral pterygoid mm
Can also be used in home program.
Joint Mobilization (intraoral):
Goals:
Restoration of motion by affecting capsule
Muscle relaxation through stimulation of mechanoreceptors
Recapture disc
a) Distraction
b) Distraction with anterior glide(translation)
c) Lateral glide
d) Self-mobilization (home program)
e) Dynamic loading/unloading with stacked tongue depressors
**Restoration of translation should be primary focus, for it is usually accessory movement most restricted and the most difficult one to regain
Controlled opening (mirror exercise)
Goals:
Provides non-traumatic, symmetrical opening
Visual feedback
Muscle balance re-education
Active stretching
Intraarticular: open/close without creating click/pop
Extraarticular: open/close with symmetrical motion
*patient may use fingertips to palpate condyles for additional feedback*
Jaw relaxed position:
Train patient to keep tongue on roof of mouth, this will keep teeth apart and unload the joint
As a home exercise have the patient make a "clucking" sound to reinforce the relaxed position
Can be use for intra/extra articular conditions
Rhythmic stabilization:
Goals:
Muscle balance re-education
Strengthening
Can be used for intra/extra articular conditions.
Modalities
Ice
Heat
Ultrasound
TENS
Postural correction
**VERY IMPORTANT**
Axial extension
Scapular retraction
Stress management/Relaxation techniques
Education on parafunctional oral habits
Dental treatments:
Medication(Relaxants/NSAIDS)
Intraoral appliance – night splints
Isometric/Isotonic strengthening using manual resistance
TEAM APPROACH
Dentist/Oral Surgeon
Psychologist
Social Worker
Physical Therapy
Occasionally Anesthesia (Pain Clinic)