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Flashcards in Temporomandibular Dysfunction Deck (35)
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Describe the TMJ

Gliding joint made up of: convex articular condyle of the mandible and concave articular fossa on squamous portion of temporal bone

Separated by a fibrocartilaginous articular disc — 3 parts of disc: thick anterior band, thin intermediate zone, thick posterior band


Describe TMJ changes in terms of the meniscus with mouth closed vs. mouth open

Meniscus with mouth closed: condyle is separated from the articular fossa of the temporal bone by the thick posterior band

Meniscus with the mouth open: condyle is separated from the articular eminence of the temporal bone by the thin intermediate zone


Muscles of mastication that depress mandible initially, then pterygoids take over

Digastric, suprahyoid


Action of left lateral and medial pterygoids

Move mandible lateral and forward to the right


Muscles of mastication responsible for tight jaw closure

Temporalis, masseter, medial pterygoid


Actions of buccinator, depressor labii inferior, depressor anguli oris and platysma, mentalis

Buccinator = approximates lips and compresses cheeks (blowing)

Depressor labii inferior = protrudes lower lip (pouting)

Depressor anguli oris and platysma = draws corners of mouth down

Mentalis = draws tip of chin upward


Actions of orbicularis oris, zygomatic minor, and levatror anguli oris

Orbicularis oris - approximates and compresses lips

Zygomatic minor - protrudes upper lip

Levator anguli oris - lifts upper border of lip on one side without raising lateral angle (snarl)


Actions of zygomaticus major and risorius mm

Zygomaticus major = raises lateral angle of the mouth

Risorius = approximates lips and draws lips and corners of mouth lateral (grimace)


Symptoms/signs of TMJ dysfunction

Most often c/o facial pain, HA, ear sxs, TMJ pain, or sxs of jaw dysfunction

Cephalgia, otalgia, neck pain, eye pain, shoulder/back pain, tinnitus, dizziness

May describe pain as a dull ache with difficulty opening mouth (click/crepitans), lateral jaw deviation, spasm within facial muscles, onset of TMJ symptoms may correspond with onset of stress or added stressors


Behavioral associations with TMJ

Nocturnal bruxism (controversial)

Jaw clenching (anxiety, stress)


Types of TMJ dysfunction

Opening click

Closing click (reciprocal clicking)

Inability to fully open jaw (close-locked)

Inability to close if TMJ symptoms are bilateral

Crepitus and grating

Fusion of the joint (ankylosis)


Causes of jaw clicking

Almost always d/t disc displacement (after disc is thin/stretched)

other causes: Adhesions, uncoordinated muscle action of pterygoids, tear or perforation of disc, osteoarthritis, occlusion imbalance


Important components of patient hx to ask about when pt c/o TMJ symptoms

PMH of jaw trauma
Sleep habits/position
Symptoms of bruxism
Use of mouth orthotics
Symptoms of depression/anxiety
Recent stressful events

Also personal habits like usual posture, nail biting, or frequent gum chewing


General Etiologies of TMJ dysfunction

Trauma (direct, whiplash, third molar extraction, intubation)

Malocclusions of maxillary and mandibular teeth

Muscle strain (oral habits, postural/work, sports)

MSK problems or Somatic dysfunction

Compensatory changes (short leg syndrome, scoliosis)

Developmental abnormalities (condylar hypoplasia/agenesis)

Mood disorders (anxiety, depresion, PTSD, hx of abuse)

Endocrine, hypocalcemia (Chvostek’s sign, Trousseau sign)


What type of TMJ injury results from direct blow to the joint with a closed mouth?

Posterior capsule injury


Types of malocclusion

Class 1 = 1st molars normal, problems elsewhere

Class 2a = lower 1st molar posterior to upper mandibular retrusion (overbite)

Class 2b = lower 1st molar posterior to upper to greater degree (larger overbite)

Class 3 = lower 1st molar anterior to upper mandibular protrusion (underbite)


Intracapsular problems

Metastatic Ca
Articular disc displacements


Extracapsular problems

Myofascial pain of masticatory muscles — TMJ myofascial pain syndrome, TMJ dysfunction syndrome, TMJ syndrome

NIH preferred terminology = temporomandibular muscle and joint disorder (TMJD)


Epidemiology of TMJ dysfunction

Affects about 20% of American population

MORE common in young women

#2 cause of facial pain (HA is #1)

More recent data suggest a 12-15% prevalence with 5% seeking tx due to pain/disability

Patients with RA are more likely to develop temporomandibular pain


Components of OSE for TMJ complaints

Cranial (note facial asymmetry)
Leg length (innominate shear/rotation, sacrum, SI joints)

Palpate joints for crepitans/clicks, palpate mastication muscles w/ 2-3 lbs of presure for tenderness, ROM + observe for jaw deviation, observation for cavities, suspicious lesions in mouth, teeth alignment


Components of ROM exam for TMJ complaint

Active — patient opens mouth 3-6 cm, laterally 1-2 cm, and then retracts and protrudes mandible — observe jaw movements for deviation

Passive — move pts jaw medially and laterally, with gloves feel muscles inside mouth and check for tissue texture asymmetry

[normal functional opening is 35-55 mm, functional opening in TMD pts is usually < 25 mm and often associated with pain]


What PE findings might suggest TMD?

Abnormal mandibular movements

Decreased ROM of TMJ

Tenderness of muscles of mastication

Pain with dynamic loading

Bruxism (signs of tooth wear)

Postural asymmetry

Neck and shoulder muscle tenderness

Normal CN exam


Differential diagnoses for TMD

Migraine-related disorders: carotodynia

Inflammatory dz: local infection, RA, giant cell arteritis

Dental problems: posterior teeth support loss

Neuralgias: trigeminal, glossopharyngeal

Parotid gland disorders

Lymphoproliferative disorders

Microbiology and pathology: C.tetani, odontogenic cysts, sclerosing osteomyelitis of Garre, monocystic fibrous dysplasia, acromegaly leading to prognathism

Medication side effects (steroids and avascular necrosis, bisphosphonates and osteonecrosis of the jaw)

Eagle’s syndrome (stylohyoid syndrome): elongated styloid process


Radiological exam for TMD is usually not helpful. When would you choose to do it?

Suspect dental problems

Pt with severe symptoms that don’t improve with conservative tx

Concern for alternative cause

Recent, severe trauma

[periapical radiographs can r/o tooth problems]


When radiological testing is done for TMD, what is the procedure of choice and why?

MRI — used to see position and shape of disc

[disc is commonly displaced in asymptomatic pts; MRI findings alone not significant unless TMJ movement is restricted or there is clinical suspicion for disc dislocation]


EBM TMJ level 1 interventions

CBT for chronic TMJ reduces activity interference, pain, and depression at 1 year


EBM TMJ level 2 interventions

Glucosamine sulfate for OA of TMJ
Therapeutic exercise
Physical self-regulation
CBT + biofeedback
Oral habit reversal tx
NSAIDs (usually not adequate)


EBM TMJ level 3 interventions

PT + counseling
Occlusal adjustment
Biofeedback alone
Occlusal splints (mouth guard)
Surgery (arthrocentesis, arthroscopy, orthgnathic surgery, joint replacement)


T/F: OMT used to tx TMJ has been associated with less NSAIDs and muscle relaxant use



Types of OMT techniques used for the correction of structural imbalances with TMD