TMJ anatomy
Insertion of condyle of mandible into mandibular fossa of
temporal bone.
A synovial, condylar, and modified ovoid hinged joint with
fibrocartilage joint surface.
An articular disc completely divides each joint into two cavities
What are the two movements of TMJ
rotation and gliding
When does rotation occur at TMJ
Rotation -from beginning of movement to mid-range movement
Upper head of lateral pterygoid muscles pulls the disc anteriorly
and prepares for condylar rotation - through two condylar heads
Disc provides congruent contours
When does gliding occur at TMJ
Gliding – the 2nd movement – a translatory movement
of condyle and disc along the slope articular surface
Both essential for full mouth opening and closing
Resting position TMJ
Resting position – TUTALC (tongue up, teeth apart, lips
closed)
Loose packed positiong TMJ
Loose packed position -Slightly open, teeth apart, tongue up
Restricted capsular pattern TMJ
Restricted capsular pattern -reduced opening and protraction
OR If unilateral mandible deviates to one side
Close packed positiong
Close packed position – Mouth closed, teeth tightly clenched
Movements upper cavity TMJ
• Upper cavity - gliding, translation, sliding
Movements lower cavity TMJ
Lower cavity – rotation and then hinge movement
Area of pain TMJ
- Area of pain: Pain over the TMJ joint
* In or around the ear
Muscles that could be sore TMJ
• +/- Soreness of facial mms: masseter and
temporalis
TMJ Specific Patient History
• Any pain /restriction in opening or closing mouth?
• Any pain with eating ?
• Does the patient chew on the right or left side? ( malocclusion)
• Which jaw movements cause pain?
• Do symptoms change over 24 hours? (OA)
• Provoking activities – yawning, biting, chewing, swallowing,
speaking, shouting ?
• Dos the patient breathe through nose or mouth?
• Any clicking/crepitus of the jaw ?
• Has the mouth or jaw ever locked?
• Doe the patient have any habits - smoking a pipe, leaning on
chin, chewing gum, hair, pursing and chewing lips, biting nails,
other nervous habits? – all place additional stress on TMJ
• Does the patient grind or tightly clench their teeth? (=
bruxism)
• Any related psychosocial problems ?
• Are there any teeth missing? ( deviation )
• Any teeth sensitive – indicative of tooth decay
• Any difficulty swallowing ?
Special questions TMJ patient interview
• Any thumb sucking?
• Any ear problems – hearing loss, ringing in ears, blocking,
dizziness?
• Any habitual head posture?
• Any voice changes? – may indicate muscle spasm
• Any headaches?
• Has patient had any recent dental work?
• Does the patient wear a dental plate?
P/E TMJ
- Observation: posture (poke chin)
- Active ROM (add OP)
- Resisted isometric movements
- Palpation
- Passive ROM of mandible
- Passive joint mobilisations
Observations TMJ
• Posture of head and neck (poke chin) • Facial symmetry – horizontal and vertical • Vertical should be in thirds – – hair line to bipupital line – bipupital line to nose – nose to chin Any paralysis ? Normal teeth alignment? • Any mal-occlusion - a major cause TMJ disc problems
Note occlusal position
• Class 1 occlusion = normal antero-posterior alignmemt of
maxillary teeth to mandibular teeth
• Class 2 – malocclusion – overbite of mandibular on maxillary
• Class 111 malocclusion – underbite of mandibular relative to
maxillary
AROM TMJ
Ch eck Cervical AROM – should have full ROM while keeping
mouth closed
• Flexion – mandible moves up / anterior; posterior neck
structures tight
• Extension - mandible down and back; anterior neck
structures tight
TMJ AROM (move to pain or move to limit)
• Opening /closing mouth (depression/elevation)
• Protrusion (protraction) / retrusion (retraction) mandible
• Lateral deviation of mandible left and right
How much TMJ opening do you need for normal acitivity
Need 25-35 mm for normal activity
Normal opening
Normal opening –should be straight line – and 35-
60mm ( 2-3 finger widths in mouth )
Normal lateral deviation TMJ
Lateral deviation – normal 10-15 mm
Normal protrusion -
normal >7mm
Normal retrusion (retraction)
Retrusion (retraction)- normal 3-4mm
Muscles: Elevators (closes mouth)
- Temporalis Elevators (closes mouth)
- Masseter Elevators (closes mouth)
- Medial pterygoid Elevators (closes mouth)
Muscles: Depressors (opens mouth)
- Lateral pterygoid Depressors (opens)
* Digastric Depressors (opens)
Suprahyoids action
• Suprahyoids - influence jaw position, tongue
mobility, speech, swallowing
Infrahyoids actition
• Infrahyoids - stabilise hyoid bone
Nerve supply TMJ joint
• Supplied by both cranial and cervical nerves
• CR V (trigeminal n)
– Nb. Muscle weakness may signal an UMN problem
Auriculotemporal nerve
• Auriculotemporal nerve
– Also supplies posterior capsule and blood vessels, rertodiscal pad,
typanice membrane, external auditory meatus, tragus
– Could give rise to symptoms such as tinnitus, dizziness, hearing
problems
Resisted isometric movements TMJ
• Resisted isometric movements
– Resisted opening – depression
– Resisted closing – elevation or occlusion
– Resisted lateral deviation
Reflexes TMJ
Reflexes ( jaw reflex test for cranial nerve V ) and cutaneous
distribution. Know the dermatomes.
Palpation TMJ
• Through external meatus Feel for: • Smooth movement • Equal opening R and L • Then place fingers over mandibular condyles – pain, tenderness • Palpate mandible along entire length • Hyoid / thyroid
Accessory/Joint Play Movements TMJ
- Longitudinal cephalad
- Longitudinal caudad (within the patient’s mouth)
- Lateral glide mandible (within the patient’s mouth)
- Medial glide of mandible (transverse)
- Posterior glide of mandible
- Anterior glide of the mandible
Treatment Modalities TMJ
- Soft tissue massage – masseter / temporalis
- Joint mobilisations
- Movement pattern retraining
- Neuromuscular control
- Posture retraining
- Review patient habits – chewing gum, leaning on hand
- Workplace set up
- Relaxation techniques
- Dental referral – splints,
MWM TMJ
• Anterior/inf translation of the mandible along the joint line and correct deviation as the patient opens the jaw. Pt can add OP. • 3 times reassessed. Then 3 sets of 6.
Four common conditions presenting
to physiotherapy TMJ
- Hypomobility
- Hypermobility
- Disc derangement
- Myofascial pain
Causes Hypomobility TMJ
Causes: • Disc derangement • Arthritis • Inflammation • Joint effusion • Myofascial pain • Muscle spasm • 2° to parafunctional habits
Treatment hypomobility TMJ
Treatment: • Joint mobilisation • Active exercise • Passive stretching • Exercises for muscle relaxation using mirror for biofeedback • Correct muscle imbalance • Posture correction
Causes hypermobility TMJ
Causes: • Lax capsule and ligs • Systemic hypermobility • Disc displacement • OA • Psychiatric disorders • Parafunctional habits eg. prolonged bottle feeding, thumb sucking, dummy use in children • Habitual wide opening of mouth
Treatment hypermobility TMJ
Treatment: • Jaw control, • tongue on roof of mouth while opening, guide movement of mandible, control anterior translation • Use of mirror for biofeedback • Posture correction • Concentric/eccentric exercise • Isometric exercise
Causes disc dereangement TMJ
Causes: • Mal-occlusion - condyle displaces post during closing • Trauma – partial tear of disc from capsule • Excessive pressure - from clenching or trauma • Incoordination of pterygoids - so disc snaps over condyle on opening • Degeneration • Stretching of ligaments – eg. by frequent subluxation
Treatment disc derangement TMJ
Treatment: • Locked jaw: • distract mandible away from opposing joint surface, thumb inside mouth • Avoidance of exacerbating factors • Heat • Soft diet • Surgery
Causes myofacial pain TMJ
No organic disease or joint derangement • Dull ache unilaterally • H/A and neck pn • Aggravated by chewing, tension • May be present on waking (night bruxism (grinding)) • Symptoms diffuse • Jaw stiffness • Muscles tender
Treatment myofascial pain TMJ
Treatment:
• Stretch, mobilisation
• Relaxation (TUTALC)
• Dental splint
Causes dislocation of TMJ
Yawning or taking a large bite,
Excessive contraction of the lateral pterygoids
Heads of the mandible to dislocate anteriorly
(pass anterior to the articular tubercles).
Mandible remains wide open and unable to close
A sideways blow to the chin when the mouth is open dislocates the TMJ on the
side that received the blow.
Arthritis of TMJ
TMJ may become inflamed from the degenerative arthritis
Abnormal function of the TMJ may result in structural problems
Dental occlusion and joint clicking (crepitus).
The clicking is thought to result from delayed anterior disc movement during
mandibular depression and elevation
Adhesions
Breakdown of cartilage