Flashcards in TMJ Deck (45):
What is the difference between CR and CO?
CR = condyle in the fossa with a normal loss-disc-condyle relationship
CO = condyle placement while teeth are together
What percentage of people have CR=CO? is this a problem?
about 33% have CR = CO
- it can become a problem, but only 5% of people have TMD related pain (case in which it would be treated)
What is TMD?
A collective term embracing disorders of the masticatory and cervical musculature, the TMJ’s and associated structures, OR BOTH
What does myofacial TMD usually involve?
Masseter and pterygoids
- there are 12 m's that influence mandibular motion, but those are the most problematic
- all attach primarily to condyle/ ramus and elevate the mandible (incl. temporalis)
- known as the supramandibular group
What m's are included in the inframandibular group?
All depress the mandible
What is the most unstable part of the TMJ?
- Attaches the articular disc to poserterior part of the joint
- Not a lot of tough collagen, highly vasuclarized, highly innervated
- With time, disc slips forward
How much mandibular depression is due to rotation and translation?
- Rotation = first 20-25mm
- Translation = last 15-20,,
What is the significance of location of pain in TMD?
- Muscle problem = pain in m location
- joint problem = pain right IN the joint
How do you distinguish a true closed lock from m tension/spasm?
Closed lock = hard end feel
M guarding = you can push beyond the "end" range and open the jaw more
What are causes of non-articular TMD (due to muscle)?
1. Muscle spasm
2. Myofascial pain and dysfunction (MPD)
4. Myotonic dystrophies
5. Myositis Ossificans progressiva
6. Growth disorders
What are the causes of articular TMDs?
1. Noninflammatory arthropathies: Primary OA, Secondary OA, Internal derangement (loose disc), Bone/Cart disorders with articular manifestations, and JOINT ANKYLOSIS
2. Inflammatory arthropathies: Synovitis, Capsulitis, RA, JRA, Seronegative polyarthritis, Ankylosing spondylitis, Psoriatic arthritis, and Infectious arthritis
3. Neoplasm: Pseudotumors (synovial chondromatosis), Benign (chondroma, osteotoma), Malignant (primary, metastatic)
4. Diffuse connective tissue disorders
5. Growth disorders: Developmental (hyperplasia, hypoplasia, dysplasia), and Acquired (condylolysis)
What are the nonsurgical management methods of TMD?
1. Diet modification: Full liquids, Pureed (Mashed potato consistency)
2. Moist heat (as much as possible)
3. Splint therapy - brings mandible forward, resulting less m engagement
4. Dental equilibration: attempt to make CR = CO
6. Medication: NSAIDS, Steroids, M relaxants, Analgesics (generally not prescribed), anxiolytics, antihistamines, antidepressants, local anesthetics (inj into TrP)
Why will splint therapy work for only 50% of people and it will worsen problems in 50% of people?
- 50% of people’s TMD will subside with a muscle guard
- 50% will get worse because they use it as a chew toy; splint built by dentists causes glide
What is the acute flare-up protocol for non-surgical management of TMD?
1. Mashed potato consistency diet for 2 weeks
2. NSAIDS around the clock for 7-10 days
3. Muscle relaxants for 10-14 days
4. Splint wear full time
5. Warm compresses as much as possible
6. Physical Therapy
7. Behaviour / Stress Modification
What is brisemont procedure?
forced manipulation under general anaesthesia, fully paralyzed, for diagnostic and therapeutic reasons—eg. Ankylosis
- Allows for physical exam without m guarding
Why does Botox only work temporarily?
habits haven't changed
- TrP develops in another place of m
- generally not used, saline injections yield similar results for less money
Acute closed lock treatment: Injects fluid into joint space and flushes it out; Basically a lavage in the joint space; Reduces inflammatory mediators; Sometimes diagnostic; gives idea about how joint is functioning
What is surgical management of TMD?
1. Arthrocentesis - For acute closed lock (less than 3 months) or inflammatory purposes
2. Arthroscopy - diagnostic, can do arthrocentesis at same time, disc repair and lysis of adhesions
3. Discectomy without replacement
4. Discectomy with replacement
5. Disc repositioning
6. Disc repair
7. Condylotomy (re-shaping the condyle)
8. Condylectomy (removing condyle)
9. Eminectomy (Shaving the articular eminence to make it more flat)
Which way will the jaw deviate if there is a broken condyle or condylectomy?
jaw will deviate to ipsilateral side
Composed of the mandibular condyle and synovium attached to the distal aspect of the disc; Joint capsule is taut in the inferior compartment to allow for pure rotation of the condyle in the fossa; Initial motion of jaw opening occurs in the inferior compartment as pure rotation
Inferior compartment of the TMJ
Composed of the temporal fossa/eminence and the superior synovium attached to the disc; Joint capsule is loose in the superior compartment to allow for translation; Translation of the condyle on the eminence occurs after rotation; Late joint motion usually occurs here
Superior compartment of the TMJ
This limit limits extreme opening and provides prodection for blood and nerve supply
_______ provides stability by attaching to anterior
aspect of disc. _____ and _____ ligaments including the collaterals attach the
disc to the condyle.
Anterior capsule; Medial; lateral
protects the superior joint structures and assists in
condylar translation while protecting at maximum opening
What are the TMJ's check reign ligaments in extreme opening?
Stylomandibular and sphenomandibular
Lateral excursion results in [ipsi/contralateral] spinning and [ipsi/contralateral] translation
Mover actions of:
- Lateral pterygoid
- medial pterygoid
1. Temporalis – guides biting motion to close the jaw and laterally deviates jaw – cn 5
2. Lateral pterygoid – depresses and protrudes the mandible and guides disc movement by pulling the condyle and disc forward – CN 5
3. Medial pterygoid – elevates or closes jaw – CN 5
4. Masseter – initiates elevation of mandible and is considered the strongest elevator of the jaw (Muscle of mastication) – CN 5
5. Digastric muscles pull or depress the mandible inferiorly – Anteroir belly (CN5) – Posterior belly (CN7)
6. Hyoids initiate jaw opening.
What is the "position of rest"
1. Slightly open (teeth NOT touching)
2. Lips together
3. Tongue lightly on the roof of the mouth
Created by posterior rotation of cranium and loss of cervical lordosis.; Creates muscle tension and tissue entrapment; Less than 20 mm of space noted between occiput and C2 (2 fingers in width); Changes jaw positioning by causing mandibular retraction and distal occlusion; This creates muscle overuse and tension, thereby changing jaw mechanics.
Mechanical entrapment neuropathy
what are the components of the craniomandibular system?
cranio-cervical joints and craniomandibular joints
- Neck and jaw position need to be evaluated together when considering facial pain.
- Cervical spine positioning and muscle tightness effect jaw mechanics and vice versa.
- Most important area of examination in the cervical spine is the suboccipital region including C2
- Neck pain experienced in up to 70% of TMD cases reported
What stage of joint derangement are:
- Disc displacement/ dislocation with reduction (reciprocal click)
- Disc location without reduction (closed lock)
- Disc displacement/ dislocation with reduction (reciprocal click) = Stage I-II
- Disc location without reduction = Stage III
What are the inflammatory processes that can occur in TMD?
1. Retrodiscitis – irritation of the posterior aspect of the joint
2. Capsulitis and synovitis – will cause pain due to swelling irritating nerve tissue
3. Arthritis (stage IV-V)
Thought to result from excessive or premature translation of condyle; Parafunction causes microtrauma to the disc and ligamentous tissue; Mouth breathing leads to an increase in muscle activity and changes jaw positioning
- Hypermobility creates anterior disc migration and possible synovium trauma.
- Ultimately a vicious cycle is created
- Almost 80% of those with TMJ hypermobility and parafunction will develop problems versus only 16% for those that have hypermobility alone
When assessing pain in the synovial folds, what does anterior vs posterior pain represent?
- Anterior pain is an acute response to inflammation
- Posterior pain is a longer standing problem
When pain mapping what does Pain # 1, 4, 5, 7, 8 represent?
Pain #1 usually occurs early in dysfunction.
Pain #4 usually due to malocclusion.
Pain #5 indicates start of disc displacement.
Pain #7 start of degenerative process.
Pain #8 posterior joint compression.
- #1 = anterior = acute and more concerning
What ratio relationship should there be between opening: lateral excursion: protrusion?
As the __________ tightens rotation ends and translation begins.
What are S and S for muscular TMD that need to be investigated?
1. Jaw clicking
3. Facial pain
4. Jaw locking
5. Ear pressure
6. Ear pain
7. Ear ringing
8. Tooth sensitivity
9. Muscle tension
10. Malocclusion = not coming together naturally and normally
11. Jaw deviation
12. Neck pain
13. Suboccipital tenderness
What indicates a shorter upper lip?
upper should cover ¾ upper teeth when smiling
- short upper lip – may work hard to keep upper lip down
What should you palpate during your examination?
2. Lateral Pterogoid – just below the zygomatic arch w/middle finger and
pointer finger; myofascial release
3. Temporalis Tendon – just superior to zygomatic arch
4. Intraoral Palapation – he doesn’t do because they HURT
5. Anterior versus posterior TMJ
6. Laterally Deviate, then feel condyle of contralateral side – anterior and posterior,
assess for pain
What are PT treatments for TMD?
1. Education - parafxn'l habits
2. Proprioceptive training
3. Postural correction
4. Manual therapy
5. Relaxation training
6. Stabilization exercises
7. Flexibility and ROM
8. Modality management
What are the proprioceptive training used in treating TMD?
1. Rest positioning – The tip of the tongue resting gently against the roof of the mouth at rest. - habit
2. Controlled opening – Proprioceptive feedback from the tongue to stabilize for pure rotation in the joint.
What are the manual therapy options for treating TMD?
1. Soft tissue mobilization
2. Joint glides
3. Long axis distraction
4. Manual stabilization training - isometrics
5. Cervical spine mobilization and postural correction
What are the modality options for treating TMD?
1. Ultrasound - Want small sound head; Frequency of 3 MHz
3. Iontophoresis - If inflammatory process is still present
4. Electrical Stimulation (TENS)
5. Low-Level Laser (he doesn't think this makes a difference of low level vs laser alone)
5. Biofeedback - Visual, auditory, etc to relax masseter for ex
6. Hot and Cold Therapy
- Pain at the end of the day, talk a lot = Ice massage – 5 mins on, 5 mins off, etc
- Contrast, heat/ice
- Wake up in the morning and have pain = Heat – could have some clenching etc