Temporomandibular Joint

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Temporomandibular Joint

  1. 1. Temporomandibular Joint Structure, Function, Dysfunction and Treatment Chris Keating
  2. 2. Overview <ul><li>Durable </li></ul><ul><ul><li>Can withstand 597N from women and 847N from men. </li></ul></ul><ul><li>Moved very often </li></ul><ul><ul><li>Phonation, mastication, swallowing, facial expression </li></ul></ul>
  3. 3. Anatomy-Bone <ul><li>Zygomatic </li></ul><ul><ul><li>Arch </li></ul></ul><ul><li>Sphenoid </li></ul><ul><li>Temporal </li></ul><ul><li>Mandible </li></ul><ul><ul><li>Head </li></ul></ul>
  4. 4. Anatomy- Muscles <ul><li>Masseter </li></ul><ul><ul><li>elevates and protrudes mandible </li></ul></ul><ul><li>Temporal </li></ul><ul><ul><li>elevates and retracts mandible </li></ul></ul><ul><li>Innervation: </li></ul><ul><li>Mandibular (V3) </li></ul>
  5. 5. Anatomy- Muscles <ul><li>Lateral Pterygoid </li></ul><ul><ul><li>Bilaterally- protraction </li></ul></ul><ul><ul><li>Unilaterally- contralateral swing </li></ul></ul><ul><li>Medial Pterygoid </li></ul><ul><ul><li>Elevation, protrusion, unilaterally: grinding </li></ul></ul><ul><ul><li>Innervation: Mandibular (V3) </li></ul></ul><ul><ul><li>Digastric-opening </li></ul></ul>
  6. 6. Anatomy- Nerves <ul><li>Auriculotemporal (sensory) MMA* </li></ul><ul><li>Inferior alveolar (sensory) </li></ul><ul><ul><li>mylohyoid nerve- mylohyoid m. </li></ul></ul><ul><li>Lingual (sensory) </li></ul><ul><li>Buccal (sensory) </li></ul><ul><li>muscular branches (to muscles of mastication) </li></ul>Chorda tympani
  7. 7. Anatomy- Arterial Supply <ul><li>Deep Auricular </li></ul><ul><li>Anterior Tympanic </li></ul><ul><li>Middle Meningeal </li></ul><ul><li>Maxillary </li></ul><ul><li>External carotid </li></ul>
  8. 8. Anatomy- Ligaments Sphenomandibular Stylomandibular -limits protrusion movement Joint capsule Lateral ligament -limits depression, posterior movement
  9. 9. Anatomy- The 4 Joints <ul><li>Synovial joint </li></ul><ul><li>Articular disc (fibrocartilage) </li></ul><ul><li>Two joint cavities </li></ul><ul><ul><li>(upper cavity) protrusion/retrusion </li></ul></ul><ul><ul><li>(lower cavity) hinge motion </li></ul></ul><ul><li>Extracapsular ligaments </li></ul>
  10. 10. Anatomy- Joint Surfaces <ul><li>Glenoid fossa formed by Posterior Glenoid Spine and Articular Eminence </li></ul><ul><li>Mandibular head of the mandible (medial and lateral poles) </li></ul><ul><li>Fibrocartilage </li></ul><ul><li>Traebecular Bone (thin/translucent) </li></ul><ul><ul><li>Deep perpendicular </li></ul></ul><ul><ul><li>Superficial parallel </li></ul></ul>
  11. 11. Biomechanics <ul><li>Disk is a biconcave (Bow Tie/Danish) </li></ul><ul><li>Convex mandible </li></ul><ul><li>Convex glenoid fossa </li></ul><ul><li>Lower joint- hinge </li></ul><ul><li>Upper joint- gliding </li></ul><ul><li>Increases congruency of boney structures </li></ul><ul><li>Pressure mainly on center of disk </li></ul><ul><li>CPP- Teeth tightly clinched </li></ul><ul><li>Capsular pattern- Limits in mouth opening </li></ul>
  12. 12. Capsule <ul><li>Highly vascular and innervated </li></ul><ul><li>Fiber runs from temporal to mandible </li></ul><ul><li>Very strong and tight in lateral/inferior fibers </li></ul><ul><li>Loose and Thin superior/anterior/medial fibers </li></ul><ul><ul><li>Prone to anterior dislocation due to capsule weakness and incongruence </li></ul></ul>
  13. 13. Articular Disk <ul><li>Collegen, GAGs, Elastin *changes may occur in proportion </li></ul><ul><li>Anterior and Posterior are innervated and vascular </li></ul><ul><li>Middle load bearing portion avascular and not innervated </li></ul><ul><li>Maintains congruency </li></ul>Bilaminar retrodiskal pad*
  14. 14. Disk attachments <ul><li>Medial and laterally to the mandible- firmly </li></ul><ul><li>Anteriorly to capsule/lateral pterygoid tendon (restricting posterior motion) </li></ul><ul><li>Posterior has 2 portions separated by fat pad </li></ul><ul><ul><li>Superior attaches to SGF and is elastic and allows for disk movement during mouth opening </li></ul></ul><ul><ul><li>Inferior to the neck of the mandible and is nonelastic </li></ul></ul>
  15. 15. Movement
  16. 16. Movement and Measurement <ul><li>Protrusion and Retrusion strictly gliding motion without rotation (6-9cm, 3cm) </li></ul><ul><li>Depression/Elevation gliding and rotation simultaneously (2 fingers Proximal IP) </li></ul><ul><li>Lateral Deviation- rotation on ipsilateral side with translation on contralateral side (1 central incisor) </li></ul>
  17. 17. Dysfunction <ul><li>Degenerative Conditions </li></ul><ul><li>Internal Derangement </li></ul><ul><li>Inflammation </li></ul><ul><li>Capsular Fibrosis </li></ul><ul><li>Osseous Mobility Conditions </li></ul><ul><li>Posture </li></ul><ul><li>Pulmonary Issues </li></ul>
  18. 18. Dysfunction- Degenerative <ul><li>OA- One TMJ </li></ul><ul><li>RA- Both TMJ </li></ul><ul><li>Severe internal derangements lead to higher chances of degenerative changes </li></ul><ul><ul><li>Tanaka, 2000 </li></ul></ul><ul><li>Degeneration of the TMJ is not a normal part of aging and degeneration is not necessarily associated with symptoms or dysfunction. </li></ul><ul><ul><li>Nannmark, 1990 and Leeuw, 1996 </li></ul></ul>
  19. 19. Dysfunction- Derangement
  20. 20. Dysfunction- Derangement <ul><li>Clicking or popping indicates severity of derangement (reciprocal click) </li></ul><ul><li>Mainly anterior due to structural weakness </li></ul><ul><li>Hypertrophy of lateral pterygoid </li></ul><ul><li>Overstretching of retrodiskel tissue </li></ul><ul><li>Sound is mandible moving in and out of disk with reduction </li></ul><ul><li>Without reduction there is a mechanical blocking of mouth opening </li></ul>
  21. 21. Dysfunction- Inflammation <ul><li>Rheumatoid Arthritis- S ystemic </li></ul><ul><li>Gout - Urate crystals </li></ul><ul><li>Psoriatic Arthritis- Joint pain </li></ul><ul><li>Ankylosing Spondylitis- Spinal pain </li></ul><ul><li>Systemic lupus Erythematosus- Autoimmune disease </li></ul><ul><li>***Capsular Fibrosis can be result of long term inflammation, trauma or immobilization*** </li></ul>
  22. 22. Dysfunction- Osseous Mobility <ul><li>Hypermobility due to many causes but can result in endrange sticking or feeling of jaw going out of place. </li></ul><ul><li>Palpation of lateral pole reveals large indentation </li></ul><ul><li>Deviation to the contralateral side </li></ul><ul><li>Dislocation creates same symptoms </li></ul><ul><li>No significant difference in occurrence between pt with or without symptoms of TMJD </li></ul>
  23. 23. Dysfunction- Posture <ul><li>Signs and symptoms of cervical spine injury parallel that of TMJ s/s </li></ul><ul><li>Postural stresses that injure the c-s also apply stresses to the TMJ (OA joint, subocciptial, stylohyoid, digastric) </li></ul><ul><li>Proper screening of TMJ can limit progression of dysfunctions </li></ul><ul><li>Pulmonary issues/distress can promote a forward head posture recreating postural stresses. (Restrictive Disease, Chronic use of assessory muscles) </li></ul>
  24. 24. Patient History <ul><li>Is there pain on opening or closing? </li></ul><ul><li>Pain with eating? </li></ul><ul><li>What movements cause pain? </li></ul><ul><li>Mouth breather? </li></ul><ul><ul><li>May lead to changes in internal pressure due to tongue placement which in turn alters external pressure (buccinator/orbicularis oris). </li></ul></ul><ul><ul><li>Leading to balance problem in the neck </li></ul></ul>
  25. 25. Patient History <ul><li>Any clicking? (one or two?) </li></ul><ul><li>Has your jaw or mouth ever locked? </li></ul><ul><li>Oral habits? </li></ul><ul><li>Teeth grinder (Bruxism)? </li></ul><ul><li>Teeth sensitivity? </li></ul><ul><li>Any difficulty swallowing? </li></ul><ul><li>Ear problems? </li></ul><ul><li>Headaches? </li></ul><ul><li>Voice changes? </li></ul><ul><li>Felt dizzy or faint? </li></ul><ul><li>Dental splints? </li></ul><ul><li>When is the last time they saw a dentist? </li></ul>
  26. 26. Observation <ul><li>Cervical posture </li></ul><ul><li>Bite (under, over, cross, mal) </li></ul><ul><li>Profile </li></ul><ul><li>Tongue movement </li></ul><ul><li>Bony contours </li></ul>
  27. 27. Examination <ul><li>AROM (neck, mouth) </li></ul><ul><li>PROM- rarely done </li></ul><ul><li>MMT </li></ul><ul><li>Compensations? </li></ul><ul><li>Abnormalities (C-type, deviation) </li></ul><ul><li>Chin movement normally towards painful joint (Early-spasm of pterygoid :: Late- Capsular) </li></ul><ul><li>Palpation </li></ul><ul><li>Functionality </li></ul>
  28. 28. Special Tests <ul><li>Imaging- X-ray, MRI </li></ul><ul><li>Reflexes (jaw) </li></ul><ul><li>Dermatome </li></ul><ul><li>Cranial nerve testing </li></ul><ul><li>Auscultation </li></ul><ul><ul><li>Crepitus (DJD) </li></ul></ul><ul><ul><li>Clicking (Derangement) </li></ul></ul><ul><li>Chvostek test </li></ul><ul><ul><li>Tap parotid gland under masseter muscle </li></ul></ul><ul><ul><li>+ if facial muscles twitch </li></ul></ul>
  29. 29. Treatment-Initial <ul><li>Splints </li></ul><ul><li>Modalities (Heat, Ice, Laser*-more effective?/Estim-TENS, US T/NT) </li></ul><ul><li>Muscle Techniques </li></ul><ul><ul><li>Relaxation, Strengthening, Stretching, Massage </li></ul></ul><ul><li>Joint mobilization (one joint at a time) </li></ul><ul><ul><li>Caudal, Lateral, Medial, Posterior, Anterior </li></ul></ul>
  30. 30. Treatment- Surgery <ul><li>Arthroscopic </li></ul><ul><ul><li>Lateral release, manipulation, injection “lysis and levage” </li></ul></ul><ul><ul><li>Walker repair reported as 86% successful </li></ul></ul><ul><ul><li>Very effective in conjunction with PT* </li></ul></ul><ul><ul><li>Significant decreases in pain and increases in function* </li></ul></ul><ul><ul><li>Therapy started within 24 post-op </li></ul></ul>
  31. 31. Stage I- first 2 weeks post-surgery <ul><li>Ice pack </li></ul><ul><li>Postural correction </li></ul><ul><li>Resting tongue position instruction </li></ul><ul><li>Active therapeutic exercises with tongue </li></ul><ul><li>Active controlled condylar rotation </li></ul>
  32. 32. Stage II- 3–6 weeks post-surgery <ul><li>Moist hot pack </li></ul><ul><li>Ultrasound </li></ul><ul><li>Postural correction </li></ul><ul><li>Gentle periauricular massage </li></ul><ul><li>Active to assistive exercises </li></ul><ul><li>Active vertical and lateral mandibular movement </li></ul><ul><li>Isometric exercises </li></ul><ul><li>Gentle stretching exercises </li></ul><ul><li>Home exercise program </li></ul>
  33. 33. Stage III- after 7 weeks <ul><li>Myofascial release technique for masticatory muscles and neck muscles </li></ul><ul><li>Intrinsic condylar mobilization </li></ul><ul><li>Rhythmic stabilization technique </li></ul><ul><li>Patients normally recover within 9-12wks </li></ul>
  34. 34. Reference <ul><li>Clinical Management of a Patient Following Temporomandibular Joint Arthroscopy </li></ul><ul><ul><li>Pbys Tber. 1992; 72:355-3G4.1 </li></ul></ul><ul><li>Walker Repair of the Temporomandibular Joint </li></ul><ul><ul><li>2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:1958-1962, 2007 </li></ul></ul><ul><li>A Systematic Review of the Effectiveness of Exercise, Manual Therapy, Electrotherapy, Relaxation Training, and Biofeedback in the Management of Temporomandibular Disorder </li></ul><ul><ul><li>Physical Therapy . Volume 86 . Number 7 . July 2006 </li></ul></ul><ul><li>The effect of physiotherapy on post-temporomandibular joint surgery patients </li></ul><ul><ul><li>D. W. OH, K. S. KIM & G. W. LEE Physiotherapy Section, Department of Rehabilitation Medicine, Yongdong Severance Hospital, Seoul, South Korea </li></ul></ul><ul><li>Arthroscopic management of a temporomandibular closed lock </li></ul><ul><ul><li>Australian dental journal 1998:43;(5):301-304 </li></ul></ul><ul><li>http://www.dentistrytoday.net/ME2/Segments/Publications </li></ul><ul><li>http://www.activebodyclinic.com/common_TMJ_Thesis.html </li></ul><ul><li>Orthopedic Physical Assessment </li></ul><ul><ul><li>4 th , Magee </li></ul></ul><ul><li>Joint Structure and Function </li></ul><ul><ul><li>4 th , Levangie and Norkin </li></ul></ul><ul><li>Grant’s Atlas of Anatomy </li></ul><ul><ul><li>11 th , Agur and Dalley </li></ul></ul><ul><li>Essential Clinical Anatomy </li></ul><ul><ul><li>3 rd , Moore and Agur </li></ul></ul>

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