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TMJ DysfunctionCarl Heldman PT, DPT, MA, MTC, ATC, FAAOMPT

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From the Dental Perspective

Beginning to broaden the scope

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Osseous Components

Cartilage and Synovium

Articular Cartilage

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Articular cartilage

Synovial Fluid

Functions of the synovial fluid include lubrication of the joint, phagocytosis of particulate debris, and nourishment of the articular cartilage. �

Joint lubrication is a complex function related to the viscosity of synovial fluid and to the ability of articular cartilage to allow the free passage of water within the pores of its glycosaminoglycan matrix. �

Application of a loading force to articular cartilage causes a deformation at the location. It has been theorized that water is extruded from the loaded area into the synovial fluid adjacent to the point of contact. �

The concentration of hyaluronic acid and hence the viscosity of the synovial fluid is greater at the point of load, thus protecting the articular surfaces.

Articular Disc

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Articular Disc

Articular Disc Regions

Retrodiscal Tissue

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Ligaments

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Neuro-vascular Supply

CN V

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Supramandibular Muscle Group �

Temporalis Muscle

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The Masseter muscle

The Pterygoids

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Inframandibular: Suprahyoids

Inframandibular: Infrahyoid

Biomechanics

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Biomechanics

Functional Motion

Evaluation

The evaluation of the patient with temporomandibular pain, dysfunction, or both is like that in any other diagnostic work up. � This evaluation should include a thorough history, a physical examination of the masticatory system, and problem-focused TMJ radiography (if available)

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Questions

Jaw specific Pain-talking, chewing, yawning

Popping or clicking

Catching or locking

Issues opening or closing

Grinding/clinching

Dental work-type (orthodontics)

Night guard- or oral appliance

Cranio-facial specific Ear symptoms

Change with neck motions

Hx of HA

Trauma hx including whiplash

Stress- Work/Life

Other pathoanatomical considerations

Functional Questionnaires

Jaw Functional Limitation Scale Ohrbach R. et al J Orofac Pain 2008

Oral Health Impact Profile Montero-Martin J. et al J Clin Exp Dent 2009

Temporomandibular Disorder Disability Index Streigerwald and Maher created

“Reliability and validity not yet measured” Cleland J. Palmer J. J Orthop Sports Phys Ther. 2004

Psychological Evaluation

Many patients with temporomandibular pain and dysfunction of long-standing duration develop manifestations of chronic pain syndrome behavior.

May include gross exaggeration of symptoms and clinical depression.

Comorbidity of psychiatric illness and temporomandibular dysfunction can be as high as 10% to 20% of patients seeking treatment �

1/3 suffering from depression at the time on initial presentation, whereas more than two thirds have had a severe depressive episode in their history.

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Imaging

Radiographic Evaluation

Panoramic Radiography One of the best overall radiographs for screening evaluation of the TMJs is the panoramic radiograph

Tomograms The tomographic technique allows a more detailed view of the TMJ.

Imaging continued

Temporomandibular Joint Arthrography was the first technique available that allowed visualization (indirect) of the intra articular disk

Computed tomography (CT) provides a combination of tomographic views of the joint, combined with computer enhancement of hard and soft tissue images.

Magnetic Resonance Imaging

The most effective diagnostic imaging technique to evaluate TMJ soft tissues

Allows excellent images of intra articular soft tissue, making MRI a valuable technique for evaluating disk morphology and position

Can be obtained showing dynamic joint function in a cinematic fashion, providing valuable information about the anatomic components of the joint during function.

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Examination

The physical examination consists of an evaluation of the entire masticatory system.

The head and neck should be inspected for soft tissue asymmetry or evidence of muscular hypertrophy. �

The patient should be observed for signs of jaw clenching or other habits.

The masticatory muscles should be examined systematically. The muscles should be palpated for the presence of tenderness, fasciculations, spasm, or trigger points.

Facial Symmetry

Scars- under chin, behind ears

Masseter muscle

Lateral eye to mouth corner length versus nose-chin length

Top 1/3 of the face should equal bottom 1/3 of the face

Ipsilateral long mandible

Posture

Sitting versus standing

Occiput and C7 alignment

Finger space between C0-C2

McGregor’s plane-horizontal

Orthognathic -neutral

Retrognathic -posterior

Prognathic- anterior

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Forward head posture

Very common

Creates functional malocclusion

Hypertonicity of the SC(O)M

Hypertonicity of the lateral pterygoid

Hypertonicity of the masetter.

Forward Posture Kinetic Chain

Cervical Spine

The examination of the TMJ requires the examination/ screening of the cervical spine and its accessory motion.

Can patient maintain occlussalcontact with flexion and extension allowing mandibular glide.

Cervical extension= mandible down and back

Cervical flexion = mandible up and back.

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Sub-cranial contributions

Possible posture implications

Mandibular Examination

AROM

Depression- normal 3 fingers- about 40-45 mm

Lateral Deviation- side to side excursion about 10mm

Protrusion- starts about 4 behind maxillary incisors and goes 4-6 mm past for a total of 8-10 mm.

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Palpate Condylar Motion

Use light pressure

Posterior aspect of the condyle

Anterior aspect of the condyle

Strength

Grade 0-5

Qualifiers

S/PF; S/P; W/PF; W/P

Accessory Motions

Distraction

Anterior

Lateral (Medial)

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Palpation

Will require extra-oral and intra-oral

Mandible in a resting position (may need to teach)

Identification of involved soft tissue structures

Temporalis

Make sure to assess the Anterior, Middle and Posterior sections.

Pay attention to the tendon that goes underneath the zygomatic process

Special Tests

Jaw Jerk (Masseter) Reflex- Tap the thumb of the examiner while the mouth is held slightly open

Chvostek Sign- Tap the parotid gland that is overlying the masseter look for momentary tetany

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Bite Test

Place a barrier (tongue depressor, cotton) between molars and slowly bite down and assess location and assess location and pain Done bilaterally

Ipsilateral=muscle/tendon

Contralateral=capsulitis/synovitis

TMD Classification

Capsulitis/Synovitis

Capsular fibrosis

Masticatory muscle disorders

Hypermobility

Anterior disc displacement w/ reduction

Anterior disc displacement w/o reduction

Osteoarthritis

Anterior Displaced Disc

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Anterior Disc w Reduction

Stage 1 Disc slightly anterior, little to no pain Repetitive trauma begins to deform disc

Stage 2 Reciprocal click early opening and late closing Loss of integrity of ligamentous/intracapsular structures Increased disc deformation and impingement May develop open lock

Stage 2

Anterior Disc w/o Reduction

Stage 3 Most painful stage Reciprocal click occurs later in opening and earlier in closing Closed lock disc becomes lodged anteriorly

Stage 4 Clicking is rare, or single opening click Chronic locking w soft tissue remodeling Anterior displacement common, but may be posterior

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Stage 3

Overview Stages 1-4

Osteoarthritis

Stage 5

Radiographic degenerative changes on the condylar head and articular eminences

Evidence of remodeling and osteophytes

Marked deformity and thickening of disc

Narrowed joint space

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Treatment

Education

Neutral positioning of the neck and jaw

Cervical neutral posture

Eating modifications

Avoid “bad” oral habits

Office ergonomics

Manual Therapy

Soft tissue techniques

Joint mobilization

Neuromotor Re-education (Exercises)

Stabilization Exercises

Rocabado 6x6 Program

Tongue Clucks

Controlled Opening (TMJ rotation)

Rhythmic Stabilization of the mandible

Upper Cervical distraction

Cervical spine extension

Scapular depression and retraction

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Post-operative

Arthrocentesis

Arthroscopy

Arthroplasty

Joint Replacement (partial or complete)

Inra-oral Appliance

Commonly used

Attempt to create even contact for occlusion

Type of appliance v. usage outcomes

Used in cases of bruxism with insufficient levels of evidence for support

Macedo CR, Silva AB, Machado MAC, Saconato H, Prado GF. Occlusal splints for treating sleep bruxism (tooth grinding). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005514. DOI: 10.1002/14651858.CD005514.pub2

Overall Treatment Considerations

Patients with post-traumatic TMJ problems or with recent-onset dysfunction that is largely posture-related will generally progress quickly. Once existing mechanical dysfunctions are corrected, emphasis of treatment can be education on maintenance of good posture and oral habits.

Patients with chronic TMJ dysfunction of a non-traumatic nature are less likely to progress quickly. Often, they are systemically hypermobile, with less than optimal connective tissue quality. It is important that patients understand this and recognize the need for a long-term personal commitment to rehabilitation and musculoskeletal fitness.