- Usually females - 20-50 years old - Hx of facial head and neck trauma - Hx oof asymptomatic click from childhood or teen years - Hx of orthodontics (malocclusion) - Poor dentition - Often ectomorphic & hypermobile (Beighton score) - Referred from DDS, ENT, PCP

TMD (Temporal Mandibular Dysfunction) Flashcards by Haley Highsmith

Normal mouth opening

40 to 50 millimeters

How well did you know this?

Not at all

Perfectly

Normal mouth protrusion

8 to 10 millimeters

How well did you know this?

Not at all

Perfectly

Normal lateral excursion

8 to 10 millimeters

How well did you know this?

Not at all

Perfectly

Common signs and symptoms of TMD

Headaches, frontal, temporal & occipital (cervicogenic)
Facial pain: masseter, temporalis, TMJ region, neuralgia
Ear pain: often seen first by ENT
Pain reported with eating & opening of mouth
Abnormal movement patterns oof the mandible noted
Popping & clicking
Usually coexists with cervical pain & other upper quarter dysfunction

How well did you know this?

Not at all

Perfectly

Epidemiology of TMD

Usually females
20-50 years old
Hx of facial head and neck trauma
Hx oof asymptomatic click from childhood or teen years
Hx of orthodontics (malocclusion)
Poor dentition
Often ectomorphic & hypermobile (Beighton score)
Referred from DDS, ENT, PCP

How well did you know this?

Not at all

Perfectly

What muscles help with opening/mandibular depression

Gravity assisted & digastrics (supra hyoid group)
Assist later opening by lateral pterygoid upper portion

How well did you know this?

Not at all

Perfectly

What muscles help with closing

Masseter
Temporalis
Medial pterygoids

How well did you know this?

Not at all

Perfectly

What muscles help with protrusion

Bilateral heads of the superior lateral pterygoids & assisted by medial pterygoids

How well did you know this?

Not at all

Perfectly

What muscles help with retrusion

Posterior temporalis
Assisted by deep masseter

How well did you know this?

Not at all

Perfectly

What muscles help with lateral trusion/deviation

Contralateral contraction of medial pterygoid & lateral pterygooid
Ipsilateral temporalis & masseter

How well did you know this?

Not at all

Perfectly

Describe the osteology of the TMJ

Mandibular condyle articulates with temporal bone (mandibular fossa) via the disc.
The disc separated the joint into upper and lower joint compartments
Articular surfaces are fibrocartilage, not hyaline - fibrocartilage can repair and remodel
Biconcave disc- superior convex and inferior concave articulating with condyle
Articular eminence/tubercle anteriorly

How well did you know this?

Not at all

Perfectly

Describe the disc and capsule

Disc attached to medial and lateral poles of condyle and posteriorly to superior lamina which is elastic and allows it to stretch
Retrodiscal tissue: Superior lamina attaches to tympanic plate; Inferior lamina not elastic and attaches to neck of condyle
B/w 2 lamina is loose connective tissue that is rich in vascular and neural supply-painful when compressed
Capsule attaches inferiorly to neck of mandibular condyle; laterally and medially to circumference of temporal fossa (above disc is loose and below is tight); very vascular and innervated

How well did you know this?

Not at all

Perfectly

Describe the biomechanics of the TMJ

2 joints in one that is divided by a disc
Superior joint is larger & each joint has its own synovium
Superior joint is formed by fossa & superior surface of disc (gliding or anterior translation)
Inferior joint is formed by condyle & inferior surface oof disc (this is where anterior rotation of condyle under disc occurs)
Superior lamina allows disc to translate forward along the fossa
Inferior lamina tethers disc and limits forward translation of condyle

How well did you know this?

Not at all

Perfectly

Describe the biomechanics of mandibular depression

Opening: anterior rotation of condyle on lower disc surface (1st 25mm of opening)
Anterior translation of disc/condyle along the fossa surface (further 25mm)
Normal opening is 40-50mm

How well did you know this?

Not at all

Perfectly

Describe the biomechanics of mandibular protrusion & retraction

All translation occurs in upper joint space
Coondyle & disc translate together
Retro discal tissue stretches

How well did you know this?

Not at all

Perfectly

Describe the biomechanics of lateral deviation to the right

R condyle rotation & L condyle translation
Normal ROM is 8-10mm
1:4 ratio of lateral deviation to depression

Describe a C-Curve

-Capsular pattern of restriction
- Usually no click or pop
- Mandible deviates towards restricted side

Describe a S-Curve

Anterior displacement of disc off condyle
Anterior translation is blocked until disc reduces itself on condyle during depression
After reduction of disc then mandible returns to midline
Usually associated with click or pop

Describe deviations

Lateral movements with return to midline
The opening pathway is altered but returns to midline
Usually indicative of a disc displacement with reduction or could be neuromuscular dysfucntion

Describe deflections

Lateral movements without return to midline
Deflections are usually associated with disc dislocations without reduction or a unilateral muscle restriction

Describe the meaning of pops or clicks in the TMJ

Can be normal
Hx of parafunctional activity: Bruxism (grinding at night) common
Auscultation can be used but not necessary
Opening & closing clicks indicative of disc displacement with reduction

What would you look for in a patient’s posture/observe for TMD

Sitting/standing posture
Posture rotation of cranium
Facial symmetry
Observe with tongue in resting position
Signs of parafunctional habits: masseter hypertrophy

Describe the cervical relationship to TMJ involvement

Forward head posture (FHP) creates mandible depression, tension & fatigue of anterior supra hyoid muscles, tightening of posterior extensor mm
Thought to translate mandible superiorly & posteriorly forcing condyle up into fossa contributing to disc dislocation/cumulative tissue trauma

Normal TMJ ROM values

- Opening: 40-50mm - Closing: look at mandible position = midline, cross bite, overbite, underbite - Lateral: 8-10mm - Protrusion: 10mm - Retrusion: 5mm

Describe the TMJ compression bite test

- Comprised of forceful unilateral biting for 20 sec on a tongue depressor in the first molar region - Familiar pain on the contralateral side to the clenching side is considered a positive test for joint pain & ipsilateral pain is indicative of muscle disorder - Contralateral = joint issue - Ipsilateral = muscle issue - A patient can have both

Describe disc displacement with reduction

- Opening & closing clicks (may have 2 clicks on closing) - Disc displacement without reduction is a progression of the former - 1st opening click - 2nd opening click - Locking - 1st closing click - 2nd closing click

Describe a near screen for TMD

- Test facial nerve & UE dermatomal scan - UE deep tendon reflexes - Test Trigeminal nerve - Motor testing of mandible, lateral deviation, clenching, & opening

Describe disc displacement without reduction

- Disc remains displaced anteriorly blocking anterior rotation & translation for full opening motion - Redistricts movement to ~25mm - No click as disc is stuck in anterior position

Describe joint pain

- Dull or sharp pain at the TMJ or inside ear associated with chewing on opposite side, sleeping on same side

Describe muscle pain

- Dull ache, anterior to TMJ, at temporal region, associated with same side chewing or clenching with stress

List the functional outcome measures for TMD

- TMJ disability index (TDI) - TMJ disability index questionnaire: Steigerwald/Maher - Patient specific functional scale - TSK-TMD (Tampa scale of Kinesiophobia-TMD) if chronic pain is a factor

Describe the TMJ classifications

- Group I Masticatroy muscle disorder: Ia = with normal opening; Ib = with limited opening - Group II Disc displacement: IIa = with reduction; IIb = without reduction with limited opening; IIc = without reduction without limited opening - Group III Joint dysfunction: IIIa = arthralgia; IIIb = osteoarthritis; IIIc = osteoarthrosis

Describe primary HA Hx

- Migraine - Tension type - Cluster

Describe secondary HA

- Medical Hx of HTN, cardiac HX, angina - Systemic: RA, lupus, fibromyalgia, bilateral pain - Cervical posture, DNF strength, ROM, posture, segmental motion, palpation - Dental: Hx, teeth, bite, observation of oral cavity - Ear: Hx, otoscope, pressure over tragus - SinusL sinus pain, nasal congestion, reduced smell, sinus tap test - Eye: acute vision loss, eye pin with eye movement, palpation temporal artery - Cranial neuralgia (CNS)

Treatment interventions for TMD

- Education: dietary (softer diet, switch sides when chewing, avoid foods that require big bites), reduce parafunctiional habits (bruxism, lip biting), functional habits (avoid WBing on joint, adapted yawning - block or tongue position), psychological factors, pain science education, & coping strategies - Modalities: Estim, iontophoresis, dry needling, ultrasound (up for discussion) - Therapeutic exercises: Rocabado 6x6 program & Kraus TMD exercises

Describe Recabado 6x6 program

- 6 exercises, 6 reps, 6x/day

Describe Kraus TMD exercises

- Includes inhibition of excessive masticatory muscle activity - Neuromuscular control - Choose interventions to address pain, joint clicking, muscle asymmetry, deviations in active ROM patterns & spasms that limit opening

Lists the different joint mobilizations we can do for TMD

- Distraction - Anterior glides - Unilateral caudal lateral glide (sitting) - Medial/lateral glide - Caudal anterior medial (CAM) - Self mobilization of TMJ for medial glide - Soft tissue mobilization: friction massage, trigger point release (intra/extra oral)