TMJ and Cranium Flashcards
1
Q
How many times a day does the TMJ move?
A
1,500 -2,000 times a day
–Chewing, talking and swallowing
2
Q
How much bite force does the TMJ have?
A
Over 900 lbs per square inch of Bite Force
3
Q
What is Costen’s syndrome?
A
- Trigeminal neuralgia, tinnitus & altered sensations of tongue and throat
- Condyle compressing the Eustachian tube & nerves (chorda tympani, auriculotemporal nerve)
4
Q
What is the last joint to develop?
A
TMJ is the last joint to develop
–Meckel’s cartilage; 1stbranchial arch (malleus)
5
Q
Where does the trigeminocervical nucleus combine infor from?
A
C1-C3 and V1-V3
6
Q
Which cranial nerve refers pain to the ear?
A
Cervical portion of cranial nerve 9 & 10 refer to the ear
7
Q
Where can the trap refer pain to on the head?
A
The trapezius refers pain to the temporal area
8
Q
What cervical nerve has a dermatomal pattern under the mandible?
A
C2
9
Q
What are some common symptoms of masticatory system overload?
A
Some of the more common symptoms are
(a) tooth wear,
(b) pulpitis,
(c) tooth mobility,
(d) muscle pain,
(e) TMJ pain,
(f) earpain, tinnitus
(g) headache.
10
Q
What is the origin and insertion of the lateral pterygoid muscle?
A
Lateral portion of lateral pterygoid plate to condyle of mandible and disk
11
Q
What is the origin and insertion of the medial pterygoid muscle?
A
Medial portion of lateral pterygoid plate to the medial angle of the mandible
12
Q
What are the main muscle actions of the temporalis muscle?
A
Closing (adduction)
Retrusion (posterior glide)
Excursion (lateral glide) ipsilaterally (primary)
13
Q
What are the main muscle actions of the masseter muscle?
A
Closing
Anterior Glide
14
Q
What are the main muscle actions of the lateral pterygoid muscle?
A
–Opening (depressionAKA: abduction)-inferiorhead, bilat
–Protrusion(anterior glide) i, bilat
–Excursion(lateral glide) i, unilat, contralaterally
–Closing/Stabilization –superiorhead
15
Q
What are the main muscle actions of the medial pterygoid muscle?
A
–Closing(elevation AKA: adduction)
–Excursion(lateral glide) contralaterally
–Protrusion(anterior glide
16
Q
What are the main muscle actions of the digastric muscle?
A
–Opening(depressionAKA: abduction) p
–Protrusion(bilateral anterior bellies)
17
Q
To get left lateral glide of the TMJ what has to happen to the Right side?
A
– Relax Right side Temporalis, Masseter, and Medial Pterygoid
- Contract Right Lateral and Medial Pterygoid muscles (contralateral motion)
18
Q
To get left lateral glide of the TMJ what has to happen to the left side?
A
Contract Left Temporalis posterior belly
19
Q
What happens to the condylar head with left lateral glide of the TMJ?
A
Condylar head protrudes to the right.
20
Q
How many distinct joint compartments make up the TMJ?
A
Two distinct Non-communicating joint compartments: Upper joint and lower joint separated by a disc
21
Q
What action occurs first in the TMJ, rotation or translation?
A
Rotation is where the ginglymoarthodial joint hinges in place which happens first.
22
Q
What happens with translation of the TMJ?
A
The ginglymoarthrodial joint glides forward
23
Q
Is the upper joint of the TMJ responsible for rotation or translation of the TMJ?
A
Translation of the condyle
24
Q
How much of the TMJ movement should the upper joint should be responsible for?
A
Upper joint is responsible for 20 mms - max (55mm) upon opening
25
Is the lower joint of the TMJ responsible for rotation or translation of the TMJ?
Rotation
26
How much of the TMJ movement should the lower joint should be responsible for?
20-25mms max
27
What is deflection?
The swinging of the jaw to a certain side
28
What is deviation?
The swinging of the jaw in an "S" or "C" pattern.
29
What is the pressure test?
Compare the tenderness of the anterior belly of the temporalis to the condyle
30
When is the TMJ disk most vulnerable and why?
Most vulnerable with mouth open because disk is thinnest and most easily damaged
31
What side does the chin point to with mech obstruction?
Chin points to the side with mechanical obstruction.
32
How long of dental work does it take before a sprain/strain occurs in the TMJ?
Occurs 20 mins after dental work.
33
With chronic sprain/strains what is the most important approach?
Rehab/proprioceptive exercises
34
What are some possible causes that can cause jaw pain? (3)
1) Habits/Stress
2) Occlusion
3) Dentist/Trauma/Braces
35
What does early opening and late closing click mean and what is it called?
Anterior displacement of disc and it is known as a reciprocal click
36
What is the compression test?
```
Compare the timing and
intensity of the joint
noise while opening
under compression and
relaxation
```
37
What are the 5 C's of the physical exam of the TMJ?
1) Clicking
- Reciprocal
2) Cracking
3) Cavitation
4) Clunking
5) Crepitus
38
What does reciprocal clicking usually represent?
Usually an anteriorly displaced disc with reduction
39
What % of the population has popping or clicking of the TMJ that is "normal"?
10%
40
What does Nimmo suggest is often the cause of a stretched ligament?
Nimmo suggests that clicking is often
due to a stretched ligament and should
resolve with treatment and healing time.
41
Imbalance in what muscle of mastication can cause clicking?
• Imbalance in the Lateral Pterygoid
| muscles also can cause clicking
42
What are the most common symptoms of TMJ? (9)
1) Hearing, Tinnitus or Ear symptoms
2) Headache
3) Neck and upper shoulder muscle pain
4) Jaw pain
5) Temporomandibular joint noise (clicking, grating)
with mandibular movement
– Only when painful or associated with dysfunction
6) Limited mouth opening and/or disturbances in
capacity for mandibular movement
7) Dizziness or Vertigo
8) Pain and paresthesia in the upper extremities
9) Difficulty swallowing
43
What is the IHS diagnosis of TMD-related headache definition?
The patient must report recurrent pain in one
or more regions of the head and/or face
associated with at least one of the following:
1) Pain is precipitated by jaw movements
and/or chewing of hard or tough food,
2) Reduced range of or irregular jaw opening,
3) Noise from one or both TMJs during jaw
movements, or
4) Tenderness of the joint capsule(s) of one
or both TMJs.
44
What imaging evidence and what resolution time is required to diagnose a TMD-related headache according to the IHS?
```
1) There should be
x-ray, MRI or bone scintigraphy
evidence of TMD and
2) The headache should resolve within
3 months, without recurrence, after
treatment of the TMJ and/or related
muscles. (IHS 2004)
```
45
What are some physical exam procedures that should be done with TMJ? (6)
1) Auscultate
2) Palpate
– Lymph nodes
– Mastoid
3) Observe
– Ear/Insufflation
– Throat
4) Test
– Temp
– CN V3 (motor/sensory)
5) Kinetic chain/posture
6) Imaging (new/old)
46
What are some specific mechanical examination that should be done with TMJ? (7)
1) Range Of Motion
2) Observation (joint noise)
3) Gait Biomechanics
4) Palpation (lateral pole and EAM)
5) Forced Bite (occlusion)
6) Orthopedics
7) Request old films
47
What is the average opening of the TMJ?
55mm
48
The chin points to which side? The side of mechanical obstruction or the side that is not affected?
The chin points to
the side of the
mechanical
obstruction
49
What does premature translation on the left TMJ suggest? (4)
1) left capsular sprain,
2) underactive suprahyoid muscles (rotators)
3) overactive left lateral and medial pterygoids (protruder)
4) inhibited right pterygoids
50
How to separate capsular sprain, underactive suprahyoid muscles, overactice left (> lateral) pterygoids and inhibited right (>lateral) pterygoids?
Orthopedic tests and palpation
51
What does the resisted protrusion test assess for?
Pain is produced the inferior head of the lateral pterygoid muscle is indicated. (depends on which side experiences pain)
52
What does the left separation clench test assess for?
If the pain occurs opposite of the object then the pain is due to compression or pinching of some (tissue) or joint. If the pain occurs on the same side as the object then it is d/t distraction of the muscle on that side or a sprained capsule
53
Which is better to image the TMJ, Ultrasound or MRI?
MRI as the gold standard
54
What is the limitation of the diagnostic ultrasound on the TMJ even though it is moderately acceptable for sensitivity and specificity?
- only the lateral aspect of the disc is seen
because the medial part is anatomically blocked
from view
- Medial displacements of the disc could be
overlooked
55
When are blood tests indicated?
Blood tests are rarely indicated except in cases
where an inflammatory TMJ arthritic condition
or temporal arteritis as a cause of the jaw pain
is suspected
56
What tests are used for inflammatory arthritis?
ESR or
| CRP, RA factor and anti-CCP
57
What tests are used for temporal arteritis?
ESR and/or
CRP, a CBC with platelets and perhaps a liver
panel (AST or ALP are elevated in 15-30% of
temporal arteritis patients)
58
What are the 5 diagnostic categories of TMD?
1) Articular Joint Disorders
2) Disc Disorders
3) Bilaminar & Joint Capsule Disorders
4) Ligament Disorders
5) Muscular Disorders
59
What injuries to the TMJ can trauma cause? (5)
1) Fractures
2) Jaw
dislocations
3) Sprain
4) Strain
5) Hypermobility
60
Which side of the TMJ is more damaged, the compressed side or the distracted side?
Compressed side
61
What is retrodiscitis?
Trauma to the retrodiscal tissues can lead
to swelling. With swelling of these tissues,
the condyle can be displaced anteriorly and
inferiorly. This results in an acute
malocclusion that clinically appears as a
lack of posterior tooth contacts on the
ipsilateral side.
62
What is jawlash?
```
CAD injuring the jaw has
not shown compelling
evidence
- TMD symptoms are
commonly associated with
whiplash
```
63
What are the different chiropractic DDX's for TMJ?
```
1) Sprain/Strain
–Capsulitis
–Synovitis
–Plica
–Retrodiscitis
2) Intersegmental Dysfunction “joint dysfunction”
–Hyper/hypomobility
3) MFPS
```
64
How does a capsular sprain present? (5)
1) Pain with stretching of the capsule
– Chewing on the ipsilateral side
2) Pain with joint loading in protrusion, and with
joint distraction maneuvers
3) Palpatory pain at the capsule
4) Excessive ROM ipsilaterally when chronic
5) Possible contralateral deflection if chronic, or
ipsilateral if acute and painful
65
Is there any noise with a capsular sprain?
No
66
How does a hypermobile TMJ present? (5)
1) Opening contralateral deflection when
condyle passes the slope of the eminence
2) Capsular tenderness toward anterior joint line
3) Palpatory pain in the masticatory muscles
4) Joint clicking/clunk/thud as condyle
partially dislocates anteriorly
5) Possible joint locking in an open position
67
How does a TMJ with MFPS present? (3)
Myofascial pain dysfunction is often a
secondary component to other types of TMJ
disorders
1) Pain provocation with eating or clenching
2) Often bilateral, palpatory pain in the
masticatory muscles with palpable
myofascial trigger points
3) Palpatory pain in the cervical musculature
68
What are the 6 stages of TMD dysfunction?
1. Meniscal Hesitation (Adhesions)
2. Meniscal Attachment Damage (Internal
Derangement)
3. Stage 3 Reducible Meniscal Displacement
(Functional Disc displacement with reduction)
4. Irreducible Meniscal Displacement (Disc
displacement without reduction)
5. Resolution (Pseudodisc)
6. Degeneration (Arthritis)
69
How long does the initial stage last?
progress over approximately 4 years
70
How long does the interim stage last?
progress over about 1 year
71
How long does the terminal stage last?
progress ½-1 year
72
Which of the 6 stages make up the initial stage?
1. Meniscal Hesitation (Adhesions)
2. Meniscal Attachment Damage (Internal
Derangement)
3. Stage 3 Reducible Meniscal Displacement
(Functional Disc displacement with reduction)
73
Which of the 6 stages makes up the interim stage?
4. Irreducible Meniscal Displacement (Disc
| displacement without reduction)
74
Which of the 6 stages makes up the terminal stage?
5. Resolution (Pseudodisc)
| 6. Degeneration (Arthritis)
75
What are the 7 different disc diagnoses for the TMJ?
1) Mechanical disc derangement
2) Anterior disc displacement with reduction
3) Anterior disc dislocation without reduction
4) Medial, lateral or posterior disc
displacement
5) Perforated, torn, fragmented or worn disc
6) Unstable disc
7) Deformed disc (congenital or dysplastic)
76
What are some treatment goals of TMD?
1) Reduce pain and swelling
2) Promote soft tissue healing
3) Eliminate muscle spasm
4) Increase free range of motion
5) Restore normal motion and stability
6) Establish functional muscle balance
7) Prevent reoccurrences
77
What is the recommendation for moist heat for TMJ?
Moist heat when subacute
– 3-5 min. every hour
– Studies have shown that moist and dry heat
might be equally effective on orofacial pain
78
What is the recommendation for ice for TMJ?
```
Ice when acute
An ice pack is applied to the painful
area for 2 to 5 min or until the
tissue feels numb. Than the tissue
is allowed to slowly warm again.
This can be repeated as needed.
Ice should not be left on the
face for longer than 5 min or
tissue injury may result.
```
79
What are some TMJ physiotherapy modalities?
```
1) Electrical stimulation
– Mini pads
2) TENS
– Studies have show that pad
placement/channel balance are not
crucial
3) Ultrasound (pulsed)
– Studies have shown that tooth and
filling materials only rise a few
degrees
4) Laser
5) Iontophoresis
- Local
anesthetics and
anti-inflammatories are
commonly used with
iontophoresis.
```
80
What settings should ultrasound be put on for the TMJ?
8 mins, pulsed
81
Where can trigger points from the trapezius muscle refer to?
```
Trigger points located in the
trapezius muscle refer
pain to behind the ear, the
temple, and the angle of
the jaw.
```
82
Where can trigger points from the SCM muscle refer to?
refer pain to the temple
area (typical temporal
headache)
83
What myosfascial trigger-points refer pain to the teeth? (3)
```
1) The temporalis refers only
to the maxillary teeth.
2) The masseter refers only to
the posterior teeth.
3) The digastric anterior refers only
to the mandibular incisors.
```
84
Where does a trigger point in the semispinalis capitis refer pain to?
A trigger point in the semispinalis capitis
muscle will refer pain to the preauricular
(TMJ) area and anterior temporal region.
85
Is there a specific order to manipulation of the TMJ or Cx spine?
```
There seems to be
an importance to the
order of treatment.
–A primary neck issue
should be corrected
first
–A primary TMJ issue
should be addressed
first
```
86
What is the direction of thrust when adjusting the jaw AP/PA?
Slope of the
| Eminence
87
What is the direction of thrust when adjusting the jaw Lateral?
Anterior aspect of
| Foramen Magnum
88
What are some contraindications to TMJ manipulation? (6)
```
1) Acute stage of
Inflammatory
Diseases
2) Infection
3) Crepitus- end
stage DJD
4) Variable click -
unstable disc
5) Bone Softening
Diseases
6) Hemearthrosis - Bleeding
in joint
```
89
What 5 conditions does TMJ manipulation help?
1. Stretch the joints (muscular mobility)
2. Adhesion release (disc)
3. Capsular stretch/adhesion release
4. Disc "recapture“ (allowing an anteriorly
displaced disc to re-seat itself on top
of the mandibular condyle)
5. Plical entrapment
90
How can joint distraction of the TMJ be accomplished?
```
This can be accomplished by placing
the thumb in the patient’s mouth over
the mandibular second molar area on
the side to be distracted. While the
cranium is stabilized with the other
hand, the thumb
exerts downward
force on the molar.
```
91
What are some basic TMD exercises? (6)
1) Relaxation (tongue on roof of mouth)
2) Clench and relax
3) Linear opening (mirror/tongue on roof of mouth)
4) Stretching exercises (using fingers to separate jaw)
5) ABC's (mobilization)
6) isometric jaw exercses
92
What are some activity modifications to give a TMD patient?
```
1) Eat soft foods
– pasta, cooked
veggies,
blenderized foods
2) Avoid hard,
crunchy or
chewy foods
– raw veggies, apples,
pretzels, bagels, gum
3) Watch posture and ergonomics
4) Self-Massage
5) Avoid pounding
– running, tennis, boxing
6) Reduce Stress and Jaw
clenching or grinding
7) Avoid wide opening
– yawning, yelling, dental
appointments
8) Watch sleep posture
– Pillow (Side sleeper contour)
```
93
What are some anti-inflammatory supplements for TMD? (4)
* Bromelain 1200mg on empty stomach
* Chymotrypsin/Trypsin 800mg
* Citrus Bioflavonoids 2000mg
* Curcumin 2000mg
94
What are some sedation supplements for TMD? (5)
* Valerian 300-800mg
* Kava 100mg
* Passion flower 100mg q4h
* Melatonin .5-3mg
* PSI (NF) with Willow Bark (day & night)
95
What are some chronic tissue healing supplements for TMD?
* Multivitamin / Mineral
* Omega, Flax or GLA Oils
* Vit C 2000mg
* Zinc 50mg
* Glucosamine sulfate / GAG’s 2000mg
* Calcium lactate 50mg q4h
* Magnesium citrate 100mg q4h
* Valerian root may prevent muscle flare-ups
96
When should orthodontics or surgery be used for TMD?
```
- Noninvasive, conservative
treatments are usually best
for temporomandibular
disorders.
- Orthodontics or
surgery should be a
last resort.
```
97
What 4 medical/surgical interventions can be done for TMD?
• Meniscectomy
– Partial often better outcome than total
• Arthroscopic lysis of adhesions and joint
lavage/irrigation (arthrocentesis)
• Injections (trigger point, joint block)
• Joint replacement
– Vitek II, Christensen system
98
What is the aim of cranial therapy and which techniques are most well known?
The aim of therapeutic intent of CT physically alter the cranial
environment, including the alignment of the cranial
bones. CS an SOT are most well known
99
What iatrogenic side effects can occur with cranial therapy?
worsening of vertiginous symptoms,
| and increase in psychiatric symptoms.
100
What is the goal of cranial sacral therapy?
- The goal is to “maximize the function of the Primary
Cranial Sacral Respiratory Mechanism, to restore
weight bearing postural dynamics , and
specifically to treat lumbar vertebral disc,
and sciatic nerve problems.”
- CSF and vascular flow issues
are also addressed
