Overview of TMJ disorders and therapies

1. TMJ DISORDERS AND
PHYSICAL THERAPY
VASILEIOS ROUFAS GROUP 2

2. TEMPOROMANDIBULAR DISORDERS(TMDs)
• Different pathologies affecting
the masticatory muscles, the
temporomandibular joint (TMJ),
and related structures
• • Affects more than 25% of the
population
• • 90% of those seeking
treatment are women

3. SIGNS/SYMPTOMS
• Facial pains/Muscle spasms
• Pain/tenderness in the muscles of mastication and joint Joint sounds (popping, clicking)
• Limited jaw motion
• Jaw locking open or closed
• Headaches
• Teeth grinding
• Abnormal swallowing
• Uncomfortable “off” bite
• Inability to comfortably open/close mouth
• Dizziness/vertigo
• Ringing in the ears
• Visual disturbances
• Insomnia Tingling in hands/fingers
• Deviation of jaw to one side

4. CAUSES
• Trauma
• Excessive stress
• Arthritis of the TMJ
• Whiplash injury
• Postural abnormality
• Ligamentous laxity
• Psychosocial distress (stresses)
• Bruxism (teeth grinding)
• Unaligned teeth
• Congenital Jaw abnormalities
• Prolonged mouth breathing
• Thumb sucking

5. TMJ BIOMECHANICS
• Two motions:
• First 20mm of motion is rotation. The
mandible and meniscus move anteriorly
together beneath the articular eminence
while opening or closing.
• Second motion is translation, which slides
the jaw further forward or from side to side.
The TMJ allows the jaw to open, close,
protrude, retract, and deviate laterally.
• Mainly used for chewing and speaking
• Normal opening 35-40”
• 2 to 3 knuckles

6. PHYSICAL THERAPY
• Physical Therapy is an
important aspect in the
treatment for TMD to:
• Relieve musculoskeletal
pain
• Decrease inflammation
• Restore normal
joint/muscular movements
for oral motor function
• Correct poor posture

7. POSTURAL EXAMINATION
• Forward head
• Thoracic kyphosis
• Soft tissue dysfunctions
• Occupational activities

8. Types of treatment
• Therapeutic exercises
• Manual therapy
• Modalities
• Electromyographic(EMG) Biofeedback
• Dental splint

9. Therapeutic exercises:Tongue proprioception
and control
• Make a “clicking” sound with the tongue on the roof of the mouth.
This slightly opens the jaw with the tongue on the palate behind the
front teeth, which is the resting position of the jaw and the first
portion of relaxation exercises.
• Place tip of tongue on palate behind teeth and draw small circles.
• Place tip of tongue on hard palate and blow air out, rolling the
tongue, or making a “r r r r” sound.

10. Therapeutic exercises:Control of jaw muscles
• Begin with proper resting position of the jaw. Teach the patient
control while elevating and depressing the mandible throughout the
first half of the ROM.
• Keeping the tongue on the roof of the mouth, the patient opens the
mouth while trying to keep the chin in midline. Use a mirror for visual
reinforcement.
• If the jaw deviates to one side, teach the patient to practice lateral
deviation to the opposite side without creating pain or excessive
motion.

11. Rocabado’s 6x6 program
Six components:
• Repeat six times each
• Perform six times/day
• Targets the craniocervical and craniomandibular systems
• Educate/instruct patient during treatment

12. Rocabado’s program
1)Tongue Rest Position
• Lips together, teeth slightly apart. Anterior 1/3 of tongue against roof of
mouth with slight pressure.
• Breathe through nostrils, and use diaphragm for deep breathing.
2) Control TMJ Rotation
• While opening jaw, keep anterior 1/3 of tongue on roof of mouth to limit
movement to rotation only, no protrusion.
• Instruct patient to chew in this manner- without translation/protrusion.
3) Rhythmic Stabilization Technique
• Lightly resisted motions: opening, closing, lateral deviations

13. Rocabado’s program
4) Cervical Joint Liberation
• Distract the upper cervical vertebrae by clasping hands behind neck to stablize
C2-C7, and flex head 15 degrees for distraction.
• Not neck flexion exercise, but flexion of the head on the cervical spine.
5) Axial Extension of Cervical Spine
• Push posteriorly on the upper jaw into lower cervical spine extension and slight
flexion of the occiput.
• This reduces unnecessary cervical mm. activity and improves the functional
relationship between the head and cervical spine.
6) Shoulder Girdle Retraction
• Draw shoulders back and down.
• Restores shoulders to normal postural position to reduce tension and increase
stability.

14. Manual Therapy
• Massage
• Joint Mobilizations
• Muscle stretching (passive and
active)
• Myofascial Release
• Manual Traction • Trigger Points
• Relaxation techniques
• Reduce pain
• Increase mobility
• Restore oral range of motion

15. Massage
Masseter
• Thumb inside mouth, fingers on cheek- sweeping motion to angle of jaw
• Cross-friction massage parallel to inner and outer fibers of mm.
• If trigger point, focus there
Temporalis
• Circular motions
Sternocleidomastoid
• “Corn Cob” technique
Postural
• Face, shoulders, back of neck
• Pressure on sensitive points, massage with hard, slow, short strokes

16. Stretching tissues
If the jaw is restricted from opening, determine if the cause is:
• A dislocated meniscus, which can be repositioned by joint
mobilizations, or
• Hypomobile tissues, which can be passively lengthened with
stretching as well as joint mobilizations.

17. Stretching
• Passively increase jaw opening by placing thumbs on last molars of
lower jaw adding slight caudal pressure until patient can insert the
knuckles of the index and middle fingers
• There's also resisted stretching in mandibular opening and lateral
movements

18. Joint mobilizations
Lateral Glide
• Thumb on tongue side of last
molar
• Use whole hand to oscillate
laterally
Medial Glide
• Stand on affected side
• Thumb on lateral side of last
molar
• Glide medially

19. Electrophysical modalities
• Moist Hot Pack
• Cold Pack
• Ultrasound
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Laser
• Shortwave Diathermy

20. References
• McNeely, Margeret L., Susan Armijo Olivo, and David J. Magee. "A
Systematic Review of the Effectiveness of Physical Therapy Interventions
for Temporomandibular Disorders." PT Journal 86 (May 2006): 710-25.
Physical Therapy. 27 Jan. 2009.
• Medlicott, Marega S., and Susan R. Harris. "A Systematic Review of the
Effectiveness of Exercise, Manual Therapy, Electrotherapy, Relaxation, and
Biofeedback in the Management of Temporomandibular Disorder." PT
Journal 86 (July 2006): 955-73. Physical Therapy. 27 Jan. 2009
• Kisner, Carolyn; Lynn Allen Colby. Therapeutic Exercise, Foundations and
Techniques. 2002
• http://www.nismat.org/ptcor/tmj
http://www.nlm.nih.gov/medlineplus/ency/article/001227.htm
• http://udel.edu/~spetter/TMJWebsite/anatomy.htm