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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?

4 suprahyoids:
4 infrahyoids:

All depress the mandible


What is the most unstable part of the TMJ?

restrodiscal tissue
- 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)
3. Fibromyalgia
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
5. Orthodontics
6. Medication: NSAIDS, Steroids, M relaxants, Analgesics (generally not prescribed), anxiolytics, antihistamines, antidepressants, local anesthetics (inj into TrP)
7. PT


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

posterior ligament


_______ 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

temporomandibular ligament


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

ipsilateral spining;
contralateral translation


Mover actions of:
- Lateral pterygoid
- medial pterygoid
- masseter
- digastric
- hyoids

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.

temporomandibular ligament


What are S and S for muscular TMD that need to be investigated?

1. Jaw clicking
2. Headaches
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?

1. Masseter
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.
#1 exercise


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
2. Phonophoresis
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


What % of pt's seen by PTs are hyper vs hypo mobile?

hypermobile = 50%
- hypomobile pts are the result of hyper that led to ADD w/o reduction