TMJ

Question 1

What are the three cardinal features of temporomandibular dysfunction (TMD)?

Answer 1

Orofacial pain, restricted jaw movement, and joint noise.

Question 2

Why is the TMJ important in a head and neck examination?

Answer 2

The TMJ is one of the most frequently used joints in the body, essential for talking and eating, but often overlooked.

Question 3

What bones are involved in the TMJ?

Answer 3

Temporal bone, mastoid process, mandible, mandibular fossa, articular tubercle, and head/condyle of the mandible.

Question 4

What is unique about the articular surfaces of the TMJ compared to most other joints?

Answer 4

The surfaces are covered with dense collagen instead of hyaline cartilage, making them more pliable.

Question 5

What structures contribute to the stability of the TMJ?

Answer 5

Joint capsule, lateral ligament, and the articular disc.

Question 6

What muscles are involved in TMJ function?

Answer 6

Temporalis, masseter, lateral pterygoid, medial pterygoid, suprahyoids, and infrahyoids.

Question 7

What type of joint is the TMJ?

Answer 7

A synovial hinge joint.

Question 8

What is the resting position of the TMJ?

Answer 8

Mouth slightly open, lips together, teeth not in contact, and tongue resting gently behind the front teeth or on the roof of the mouth.

Question 9

What is the close-packed position of the TMJ?

Answer 9

Teeth tightly clenched.

Question 10

What is the capsular pattern of the TMJ?

Answer 10

Limitation of mouth opening.

Question 11

Where is the articular disc located in the TMJ?

Answer 11

Between the head of the mandible and the temporal bone (primarily the articular tubercle).

Question 12

What is the function of the TMJ articular disc?

Answer 12

Maintains congruency between the mandible and temporal bone, prevents excessive anterior translation, and assists with posterior movement of the disc during compression.

Question 13

How does the thickness of the TMJ articular disc vary?

Answer 13

The disc is thicker posteriorly than anteriorly, and the middle is the thinnest but most dense region.

Question 14

Why is the middle of the TMJ disc unique?

Answer 14

It is avascular and aneural, meaning it lacks blood supply and nerve endings.

Question 15

Where is the TMJ disc highly innervated?

Answer 15

Along the edges.

Question 16

What is the anterior attachment of the TMJ disc?

Answer 16

It attaches to the joint capsule, with fibers from the superior head of the lateral pterygoid inserting onto the anterior edge.

Question 17

How does the TMJ disc attach medially and laterally?

Answer 17

It connects to the lateral edges of the condyle via the collateral ligaments.

Question 18

How does the TMJ disc attach posteriorly?

Answer 18

It connects to the posterior joint capsule via the retrodiscal pad.

Question 19

What is the function of the retrodiscal pad?

Answer 19

It acts like a rubber band, pulling the disc back to check excessive anterior translation during mandibular depression.

Question 20

What is the significance of the retrodiscal pad’s structure?

Answer 20

It is highly vascularized and innervated, making it pain-sensitive.

Question 21

What are the two primary movements involved in mandibular depression?

Answer 21

Rotation (beginning to midrange) and translation (midrange to end range).

Question 22

Where does the rotation of the mandible occur during depression?

Answer 22

In the mandibular fossa.

Question 23

Where does the translation of the mandible occur during depression?

Answer 23

From the mandibular fossa onto the articular tubercle.

Question 24

What is the role of the articular disc during depression of the mandible?

Answer 24

It is pulled anteriorly by the superior head of the lateral pterygoid to maintain joint congruency.

Question 25

Why is both rotation and translation of the mandible essential?

Answer 25

They are required for full elevation and depression of the mandible.

Question 26

What muscles are activated during mandibular depression?

Answer 26

Suprahyoids, inferior head of the lateral pterygoid (pulls the mandible anteriorly), and superior head of the lateral pterygoid (pulls the disc anteriorly).

Question 27

What movements occur during mandibular elevation?

Answer 27

Translation (mandibular head moves from the articular tubercle to the fossa) followed by rotation (mandibular head rotates within the fossa).

Question 28

How is the articular disc repositioned during mandibular elevation?

Answer 28

The retrodiscal pad pulls the disc back into position.

Question 29

What prevents the articular disc from snapping back into place too quickly during elevation?

Answer 29

Eccentric contraction of the superior head of the lateral pterygoid controls the posterior translation of the disc.

Question 30

What muscles are activated during mandibular elevation?

Answer 30

Masseter, medial pterygoid, temporalis, and the superior head of the lateral pterygoid.

Question 31

What is Temporomandibular Dysfunction (TMD)?

Answer 31

Unilateral or bilateral pain around the ear, TMJ, teeth, head, or other associated structures.

Question 32

How can TMD pain present?

Answer 32

As tension and/or pain in the jaw, face, head, neck, and/or ear, ranging from mild, intermittent ache to chronic and debilitating pain.

Question 33

What are common symptoms of TMD?

Answer 33

• Clicking, popping, or grinding/crepitus with opening and closing the mouth. • A feeling of fullness in the ear, tinnitus, and/or earaches. • Possible locking of the TMJ with opening or closing movements.

Question 34

Does every patient with TMD experience all symptoms?

Answer 34

No, patients may experience many or only a few of these symptoms.

Question 35

What causes clicking in the TMJ?

Answer 35

The disc is displaced anteriorly; as the mouth opens, the mandibular head slips onto the disc (click), and when the mouth closes, the mandibular head slips back off the disc (click) into the fossa.

Question 36

What causes locking in the TMJ?

Answer 36

The disc is displaced anteriorly, preventing the mandibular head from slipping onto the disc, making it impossible to open the mouth.

Question 37

What is the reverse scenario of TMJ locking?

Answer 37

The disc is jammed behind the mandibular head, causing the joint to be locked in an open position.

Question 38

What are the biomechanics of mandibular depression (opening the mouth)?

Answer 38

• Beginning to midrange: Rotation of the head of the mandible in the mandibular fossa. • Midrange to end range: Translation of the head of the mandible from the fossa onto the articular tubercle. • The articular disc is pulled anteriorly by the superior head of the lateral pterygoid to maintain joint surface congruency. • Both rotation and translation are essential for elevation and depression of the mandible.

Question 39

What muscles are activated during depression (opening) of the mandible?

Answer 39

• Suprahyoids • Inferior head of lateral pterygoid (pulls the mandible anteriorly) • Superior head of lateral pterygoid (pulls the disc anteriorly)

Question 40

What are the biomechanics of mandibular elevation (closing the mouth)?

Answer 40

• Translation of the mandibular head from the articular tubercle to the fossa. • Followed by rotation of the mandibular head in the fossa (reverse of depression). • The disc is pulled back into position by the elastic retrodiscal pad fibers. • Eccentric contraction of the superior head of lateral pterygoid prevents the disc from snapping back into place.

Question 41

What muscles are activated during elevation (closing) of the mandible?

Answer 41

• Masseter • Medial pterygoid • Temporalis • Superior head of lateral pterygoid

Question 42

What is Temporomandibular Dysfunction (TMD)?

Answer 42

Unilateral or bilateral pain around the ear, TMJ, teeth, head, or other associated structures.

Question 43

What are common symptoms of TMD?

Answer 43

• Tension/pain in the jaw, face, head, neck, and/or ear. • Clicking, popping, grinding/crepitus with opening and closing. • Feeling of fullness in the ear, tinnitus, and/or earaches. • Possible locking of the TMJ with opening or closing. • Symptoms may range from mild and intermittent to chronic and debilitating.

Question 44

What is happening in the TMJ when clicking occurs?

Answer 44

• The disc is displaced anteriorly. • The mandibular head slips onto the disc when opening (click). • The mandibular head slips back off the disc into the fossa when closing (click).

Question 45

What is happening in the TMJ when locking occurs?

Answer 45

• The disc is displaced anteriorly, preventing the mandibular head from slipping onto the disc and opening. • Alternatively, the disc can become jammed behind the mandibular head, locking the joint in an open position.

Question 46

What are the three main causes of TMJ pain?

Answer 46

1. Muscles: High resting tone, active trigger points, or muscle spasms. • Head forward carriage (HFC) places passive tension on the hyoids, altering the mandible’s resting position (posteriorly and inferiorly). • Muscles work harder for talking and chewing. 2. Joints: Degeneration (OA, RA) can lead to pain, stiffness, and disc displacement. 3. Nerves: Irritation or compression of the greater occipital nerve (C1-C2) and trigeminal nerve (CN5) can cause head and face pain.

Question 47

How can TMJ structures become injured?

Answer 47

• Falls • Whiplash • Contact sports collisions • Dental work/surgery

Question 48

What patient presentations may indicate the need for TMJ treatment?

Answer 48

• Stress • Depression/anxiety • COPD (pink puffers) • Chronic sinus problems • Mouth breathers • History of whiplash • Scoliosis • Malocclusion, dental work, or dentures

Question 49

What does the knuckle test assess?

Answer 49

• Patient should be able to fit at least two knuckles between their front teeth. • More than three knuckles suggests hypermobility.

Question 50

What does pain with opening the mouth suggest?

Answer 50

A muscle problem.

Question 51

What does pain with biting suggest?

Answer 51

A joint/disc issue.

Question 52

What can cause limited ROM in the TMJ?

Answer 52

• An anteriorly displaced disc (likely with popping/clicking). • Tightness or spasm of masseter, temporalis, or medial pterygoid.

Question 53

What do different jaw movement patterns indicate?

Answer 53

• C-curve: Joint restriction on the side the mandible swings toward. • S-curve: Muscle imbalances.

Question 54

What are the typical treatment goals for TMJ dysfunction?

Answer 54

• Manage pain. • Normalize ROM. • Normalize muscle tone. • Correct posture. • Relieve nerve compression. • Address stress levels.

Question 55

What treatment techniques are commonly used for TMJ dysfunction?

Answer 55

• Myofascial techniques • Swedish techniques • Joint play of TMJ, C-spine, T-spine • Hydrotherapy (warm towels on the face)

Question 56

What are important positioning considerations during TMJ treatment?

Answer 56

Prone may not be tolerated if facial pressure provokes symptoms.

Question 57

What precautions should be taken for intra-oral treatment?

Answer 57

• Check in with the patient before starting. • Set up a communication system. • Have towels and tissues ready. • Wash gloves and keep them on a clean surface.

Question 58

What self-care strategies help with TMJ dysfunction?

Answer 58

• Relaxation and proprioceptive TMJ exercises • Wine bottle cork stretch. • Diaphragmatic breathing and relaxation techniques. • Self-mobilization (distraction) using a cotton dental roll.

Question 59

What habits may need to be addressed to prevent recurrence of TMD?

Answer 59

• Bruxism (teeth grinding). • Clenching teeth (stress response). • Improper chewing habits, nail-biting, gum chewing, • smoking. • Mouth breathing and snoring. • Poor posture. • Leaning on one hand. • Prolonged phone use. • Mouth guard use.

Question 60

What other healthcare professionals may be involved in TMJ treatment?

Answer 60

• Dentist: - Bite plates for grinding. - Denture refitting. - Malocclusion correction. • Physiotherapy. • Psychotherapy.

Question 61

Where does pain from a masseter trigger point refer?

Answer 61

• Over the eyebrow, maxilla, mandible, and molars (upper and lower). • Molars may be sensitive to pressure and temperature. • Can refer to the ear and cause unilateral tinnitus.

Question 62

Where does pain from a lateral pterygoid trigger point refer?

Answer 62

• Maxilla and TMJ region. • Pain with chewing. • Occasional ringing in the ear.

Question 63

Where does pain from a medial pterygoid trigger point refer?

Answer 63

• Throat pain. • Deep ear pain. • Difficulty swallowing.

Question 64

Where does pain from a temporalis trigger point refer?

Answer 64

• Temporal headache. • Maxillary toothache. • Pain and sensitivity of the upper teeth.

Question 65

How do you palpate the masseter extraorally?

Answer 65

• Locate inferior to the zygomatic arch on the external surface of the mandible. • Confirm by having the patient lightly clench their teeth.

Question 66

How do you palpate the masseter intraorally?

Answer 66

• Use a pincer palpation technique (between the index finger and thumb). • Follow the medial surface of the cheek until reaching the ramus of the mandible. • Move laterally from the mandible to contact the masseter. • Confirm by applying light mandibular elevation against resistance.

Question 67

How do you palpate the temporalis extraorally?

Answer 67

• Locate above the zygomatic arch. • Feel the muscle fibers fanning out over the temporal fossa. • Confirm activation by having the patient gently clench their teeth.

Question 68

How do you palpate the temporalis intraorally?

Answer 68

• Locate its attachment to the coronoid process. • Follow the medial surface of the cheek until reaching the ramus of the mandible. • With the mouth slightly open, the coronoid process becomes accessible. • Follow the ramus superiorly until finding the coronoid. • Confirm with gentle mandibular elevation against resistance.

Question 69

How do you palpate the lateral pterygoid extraorally?

Answer 69

• Have the patient voluntarily open their mouth to relax the masseter. • Palpate through the masseter, between the mandibular notch and the zygomatic arch. • If a soft spot is felt, you are in the correct place. • Palpate for tenderness at the muscle's attachment site.

Question 70

How do you palpate the lateral pterygoid intraorally?

Answer 70

• Follow the outside of the upper teeth to the uppermost rear corner of the cheek (posterolaterally). • Have the patient deviate their jaw to the ipsilateral side to increase space. • Move a little more posteriorly and superiorly. • Palpate medially toward the pterygoid plate. • Confirm by resisting contralateral deviation of the mandible.

Question 71

How do you palpate the medial pterygoid extraorally?

Answer 71

• Have the patient laterally flex their neck/head to soften the tissues. • Use a gentle hooking technique underneath the angle of the mandible. • Confirm palpation by having the patient perform contralateral deviation or clench their teeth.

Question 72

How do you palpate the medial pterygoid intraorally?

Answer 72

• Follow along the inside of the bottom molars with the index finger. • Stay in contact with the teeth and move slowly to avoid triggering the gag reflex. • From the back molars, aim further posteriorly and inferiorly toward the angle of the mandible. • Confirm palpation by resisting contralateral deviation.