Rehabilitation of Temperomandibular joint dysfunction disorders

1. TEMPOROMANDIBULAR JOINT
DYSFUNCTION REHABILITATION
Dr Kaustav Basu Thakur
MBBS, MD (PM&R)
NEUROREHABILITAION ,RHEUMATOLOGY,
PAIN INTERVENTION SPECIALIST

2. INTRODUCTION
• Symptom complex
• Caused by multiple factors
• Covering pain and dysfunction of the muscles of
mastication and temporomandibular joints
• Not life-threatening but detrimental to quality of life
• Management difficult
222-07-2020

3. EPIDEMIOLOGY
• 2nd most frequent cause of orofacial pain
• 20-30% of adult population affected
• Most affected age group: 15-45 years
• Female: Male = 5:1
• Younger adults more commonly affected
• Peaks
Disc displacement at age 30
Inflammatory degenerative joint disorders at age 50
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4. ANATOMY
• Synovial joint, condylar variety
• Articular surface covered with fibrocartilage
• Upper articular surface
1. Articular tubercle
2. Mandibular fossa
3. Tympanic plate
• Lower articular surface
Head of mandible
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6. LIGAMENTS
Fibrous capsule Lateral ligament
Sphenomandibular Stylomandibular
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8. INTRA ARTICULAR DISC
• Oval fibrous plate
• Divides joint into two compartments-UPPER & LOWER
• Concavo-convex superior & concave inferior surface
• Consists of
Anterior extension Anterior thick band
Intermediate zone Posterior thick band
Bilaminar region
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9. FUNCTIONS OF DISC
• Prevents friction
• Shock absorption
• Stabilisation of
condyle
• Distribution of weight
• Upper compartment-
gliding
• Lower compartment-
rotatory+gliding
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10. BLOOD AND NERVE SUPPLY
• Arterial supply
Superficial temporal
Maxillary
• Venous supply
Follow the arteries
• Nerve supply
Auriculotemporal
Masseteric
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12. MOVEMENTS
• Depression
• Elevation
• Protrusion
• Retrusion
• Lateral or side to side
movements
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14. MUSCLES producing motion
• Depression- lateral pterygoid
• Elevation - masseter, temporalis, medial
pterygoid of both sides
• Protrusion- lateral & medial pterygoid
• Retraction- posterior fibres of temporalis,
masseter
• Side to side- medial & lateral pterygoids of
both sides acting alternately
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15. MUSCLES CONTINUED
NAME ORIGIN INSERTION
Lateral
Pterygoid
Superior head Greater wing of
Sphenoid
Neck of mandibular
condyle
Inferior head Lateral surface of
pterygoid plate
Medial (Internal) Pterygoid Lateral pterygoid plate
of Sphenoid bone
Ramus of mandible
Masseter Zygomatic Arch Lateral surface of angle
and ramus of mandible
Temporalis Temporal fossa Coronoid process and
anterior border of ramus
of mandible
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17. CAUSES
MUSCULAR
• Trauma
• Inflammation (myositis)
• Myofascial pain
• Fibromyalgia
• Spasm
• Atrophy/ Hypertrophy
ARTHROGENIC
• Internal Disc displacement
• Disc hypomobility
• Dislocation/Subluxation
• Arthritis
• Infections
• Metabolic disease (gout)
• Capsulitis, synovitis
• Bony or fibrous ankylosis
• Malignancy
• Fracture
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18. ARTHRITIC CAUSES
• Osteoarthritis
• Rheumatoid arthritis
• JIA
• Gout
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19. CLINICAL FEATURES
• Pain
• Restriction of mandibular movement
• Joint noises
• Headache
• Hearing loss
• Tinnitus
• Dizziness
• Sensation of malocclusion
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20. CLINICAL EXAMINATION
• INSPECTION
• DENTAL EXAMINATION
• OCCLUSAL EVALUATION
• RANGE OF MANDIBULAR MOVEMENT
• PALPATION
• NEUROLOGICAL TESTS
• AUSCULTATION
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21. INSPECTION
• Inter-incisal distance on mouth opening
• Facial asymmetry
• Deviation of mouth on opening or closing
• Pre-auricular swelling
• Malocclusion
• Improper dental restoration
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22. DENTAL EXAMINATION
• Bruxism
• Cheek or lip ridges
caused by trapping of
mucosa during clenching
habits
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23. OCCLUSAL EVALUATION
• Angle’s classification
(Class I, Class II, Class
III)
• Provides information
1. occlusal relationship
2. Evidence for bruxism or
other oral habits
3. No. of missing teeth
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24. RANGE OF MANDIBULAR MOTION
• Maximum opening distance
between the incisal edges of
upper and lower incisor is
measured using scale, Boley
gauge or ruler
• Normal opening – 38 to 45 mm
• Normal opening can also be
estimated by patient’s own finger
• Normal : three finger end on end
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26. LATERAL RANGE
• Normal: 7-10mm
• Measurements made with
teeth slightly separated,
measuring the displacement
of lower midline from
maxillary midline
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27. DEVIATION ON OPENING
• Observe the opening pattern for
deviation
• The mandible often deviates
towards the affected side during
opening
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28. PALPATION
• Directly over the TMJ just
anterior to the tragus of the ear
while the patient opens mouth
slowly
• The extent of mandibular
condylar movement can be
assessed .
• Patient is asked to close mouth
slowly, and movement of the
condyle is felt posteriorly
against finger
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29. MUSCLE PALPATION
• Masseter –palpated with index
finger & thumb with jaw
clenched
• Temporalis – Patient is
clenching the teeth and at the
same time, attempting to move
the jaws sideways
• Lateral pterygoid – palpated
with a finger pushed into the
retromolar area of the maxilla
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30. AUSCALTATION
• Noise is assessed by
stethoscope
• Classified as either click or
pop or crepitus
• Difficult to determine whether
a noise is from one joint or
both
• Not routinely done
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31. DIAGNOSIS
• X ray of TMJ- Panoramic oral radiography(PANOREX)
• CT scan
• MRI
• Laboratory investigations
1. Complete blood count
2. Uric acid
3. Ra factor & Anti CCP
4. CRP
5. Calcium, phosphate, alkaline phosphatase
6. Serum creatinine , creatinine phosphokinase
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33. DIAGNOSTIC NERVE BLOCK
• To see if pain originates in
TMJ capsule
• 25-30 gauge needle
• 0.5 ml of short acting LA
• Anterior and slightly above
junction of tragus and ear lobe
• Needle touches condyle
• Advanced in anteromedial
direction for about 1 cm
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34. TREATMENT
PHARMACOTHERAPY- mainstay of Mx
• NSAIDS (COX 1 & COX 2 inhibitors)
• Anticonvulsants
• Tricyclic antidepressants
• Topical capsaicin
• Oral opioids
• Glucosamine/ chondroitin
• Corticosteroids
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35. BOTULINUM TOXIN
• Spasm of lateral pterygoid causes anterior disc
displacement
• Botox causes temporary paralysis by blocking Ach
release at NMJ
• Effect lasts few months only
• Complications include a fixed expression
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36. PHYSICAL MODALITIES
• TENS
• Ultrasound therapy
• Moist heat
• Ice massage
• Iontophoresis
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37. INTRA ARTICULAR INJECTIONS
• Local anaesthetics
• Corticosteroids
• Viscosupplementation
• Platelet rich plasma
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39. JAW EXERCISES
• Aim to directly oppose the negative effects of disuse
• The most simple method is by regular stretching within
pain tolerance
• Gentle force applied until pain of resistance is felt, and
then the position is held for several seconds
• Commercial devices to carry out this stretching exercise
(e.g. the "Therabite" appliance)
• Over time, the amount of mouth opening possible without
pain can be gradually increased
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40. MOUTH OPENING DEVICES
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41. JAW EXERCISES
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42. MASSAGE
• Friction massage
• Causes temporary ischemia and subsequent hyperemia in
muscles
• Inactivate trigger points
• Disrupt small fibrous adhesions within muscle
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43. DEVICES
• Occlusal splints
Stabilisation splint
Partial coverage splints
Anterior positioning splint
• Ear canal inserts
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44. SURGERY
• Only 20% cases need surgery
• Failed conservative
management
• Arthrocentesis
• Arthroscopy
• Meniscectomy
• Modified Condylotomy
• Joint replacement- last resort
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45. PROGNOSIS
• Benign and self limiting
• Prognosis is good
• Persistent pain may affect quality of life
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47. THANK YOU