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BRYAN LANGWHOLE BODY HEALTH PHYSICAL THERAPY
Temporomandibular Joint Disorder and Conservative
Treatment
Anatomy
Bones Mandible Cranium
Articulations Mandibular fossa of the temporal bone and the
condyle of the mandible; creating a synovial joint.Ligaments
The fibrous capsule, lateral ligament, sphenomandibular ligament, stylomandibular ligament, and mandibular-malleolus ligament.
Anatomy
Disc Fibrocartilage
Innervation Mandibular branch of the trigeminal nerve
Auriculotemporal nerve Masseteric nerve
Muscles Lateral Pterygoid Masseter Medial Pterygoid Temporalis
Blood Supply Superior temporal artery of the external carotid artery
The Tempomandibular Joint
The disc divides the TMJ into two cavities The upper synovial cavity The Lower synovial cavity
Lower Joint Compartment Formed my mandible and the articular disc Rotational movement
Upper Joint Compartment Formed by the articular disc and the temporal bone Translational movement
Therefore, there is a rotation and translation of movement with the TMJ
Biomechanics
Osteokinematics: Depression Elevation Protrusion Retrusion Lateral excursion
Open and Closed Packed Position
Open Packed of TMJ: Mouth slightly open
Closed Packed of TMJ: Mouth closed the the teeth clenched
TMJ Use
Talking Males: 12,000 words per day Females: 50,000 words per day
Swallowing Saliva 600 times daily
60 lbs of force associated with each swallow Bruxing may increase the force level to 250 lbs
Tempomandibular Disorder (TMD)
TMD = Any problem concerning the jaw jointAge: 20-40 yearsGender: Woman>MenPrevalence: 30 million AmericansIncidence: 1 million new patients every year
Pain Generating Structures
Myogenic Lateral Pterygoid Masseter Medial Pterygoid Temporalis
Arthrogenic Synovitis Retrodiscal tissue Capsule ligaments Disc (peripheral region)
TMJ Pain
Four Main Causes: Myofascial pain dysfunction syndrome Internal derangements Degenerative joint disease Temporal arteritis
Muscle Pain Maps
TMJ Dysfunction
Anterior Disc Displacement With Reduction
Anterior Disc Displacement without Reduction
Disc can displace anterior, medial, lateral, posterior or a combo (anteromedial)
TMJ Dysfunction
How does TMJ Dysfunction Occur?
1. Birth-related forceps delivery and congenital weakness of the articular ligaments
2. Traumatogenic3. Iatrogenic
a. Prolonged dental procedures b. Traumatic dental extractions c. Injudicious use of mouth prop d. Manipulation under general anesthesia e. Improper use of laryngoscope or bronchoscope
How Does TMJ Dysfunction Occur?
4. Drug: Reserpine and phenothiazines.5. Physiologic: a. Yawning. b. Sneezing. c.
Extreme opening6. Systemic: Epilepsy and other involuntary
muscle contractions.7. Long-term over-closures secondary to loss
of dentition as a result of loosening of the joint capsule
Evaluation of TMJ
Subjective Headache or maxillofacial, cervicogenic, or shoulder
pain Reports of clicking or popping Increased life-stressors
Observation Forward head and rounded shoulders Scoliosis Mouth movement with speaking Frenulum, lips, tongue scalloping, clench lines
Evaluation
Active motion Mandibular opening (40 mm) Lateral deviation (1 tooth wide, 8mm) Mandibular protrusion/retrusion Teeth clenching
Passive motion Vertical opening Lateral movements Retraction Protraction
Resisted motion (tested in neutral)
Evaluation
Palpation Crepitation, grinding, and clicking with movement Temporalis muscle Medial/lateral pterygoid muscle Anterior/posterior digastric muscle Masseter muscle
Neurological Tests Sensation Reflexes
ALWAYS ASSESS THE C/S, T/S, and SHOULDER
What We Look For
Movement Dysfunction “S” or “C” curve Asymmetrical movement Opening and translation Lateral deviation with protrusion and retrusion
Pearls of Wisdom
Cardinal Signs Unilateral joint movement Muscle tenderness A clicking and popping noise in the TMJ Limitation and/or deviation of mandibular movement.
Pearls of Wisdom
Hyperactivity or a trigger point can interfere with eccentric contraction of the lateral pterygoid muscle as it guides the disk to its resting position during mandibular closing.
Joint clicking is indicative of sliding anterior or posterior to the disc, where as crepitus us a result of degenerative joint disease or a perforation of the disc.
Therapy Modalities
Hot and cold packsVapocoolant sprayShort-wave diathermyCold laserIontophoresisJoint mobilizationsSoft tissue mobilizationExerciseEducation
Examples of TMJ Exercises
Resisted Protrusion Mandibular Opening without anterior translation
Resisted lateral excursion
Education on Proper TMJ Habits
Avoid isometric parafunctional muscle activation Clenching and chewing on pencils, pens, and
fingernailsAvoid wide moth opening greater than 3
finger widthsAvoid hard food, and cut hard and tough food
into smaller piecesChew evenly on both sides with the back
molarsUnilateral chewing on the involved sided may
be less painful because of less joint compression
Education on Proper TMJ Habits
Maintain a neutral posture of the head and neck to promote a neutral position of the mandible when chewing
Avoid a side-lying sleeping position if lateral shear of the TMJ is problematic
Hold the mandible in the resting zone to reduce activity of the masticator muscles
Avoid a forward head postureAvoid movements that produce clicking or
locking
Education on Proper TMJ Habits
Address malocclusion with dental intervention
Avoid the rest position of the tongue thrust forward, which causes protrusion of the mandible
Sleep
Sleep is essential for health The body physically renews during sleep, thus
protecting human beings from the natural wear that occurs when they are awake.
A large number of cerebral and organismal functions are influenced by sleep, as the conditions of the brain during the preceding period of wakefulness are reestablished during sleep.
Sleep
The most common causes of sleep problems: Excessive work Family responsibilities Medication use Environmental factors that harm both the quantity
and quality of sleep Changes in sleep patterns can lead to
reduced cognitive function, increased reaction time, memory loss, increased irritability and metabolic, endocrine and cardiovascular changes.
Sleeping and TMJ Disorder
The prevalence of sleep disorders and TMD in the general population is high.
Many studies have correlated poor sleep quality with chronic pain, episodes of severe pain, psychological stress and lower perceptions of self-care.
Ways to Decrease Stress
30/30 ruleMindful Based Stress Reduction
“Take 5”Jocobson relaxation technique (progressive
muscle relaxation)Exercise
Progressive Muscle Relaxation
Does PT Help?
McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther. 2006;86:710–725. Systematic Review of literature
36 relevant articles, 12 met inclusion criteria, 3 were considered strong methodological quality Postural training, manual therapy, and exercise
all demonstrated significant benefit. Active and passive oral exercises to improve
posture are effective interventions to reduce symptoms associated with TMD.
Does PT Help?
Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther.2006;86:955–973. Systematic Review
Active exercises and manual mobilizations may be effective as well as postural training in combination with other TMD interventions.
Review favored multifaceted treatment strategies.
Does PT Help
Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed-lock. J Dent Res.2007;86:58–63.
Ismail F, Demling A, Hessling K, Fink M, Stiesch-Scholz M. Short-term efficacy of physical therapy compared to splint therapy in treatment of arthrogenous TMD. J Oral Rehabil. 2007;34:807–817.
de Felicio CM, Freitas RL, Bataglion C. The effects of orofacial myofunctional therapy combined with an occlusal splint on signs and symptoms in a man with TMD-hypermobility: Case study. Int J Orofacial Myology. 2007;33:21–29.
Monaco A, Cozzolino V, Catteneo R, Cutilli T, Spadaro A. Osteopathic manipulative treatment (OMT) effects on mandibular kinetics: Kinesiographic study. Eur J Paediatr Dent. 2008;9:37–42.
Does PT Help
Conclusion summary of the 4 articlesIn general, the validity and strength of the
studies were weak. However, all evidence continued to support the
statement that physical therapy may be an effective stand-alone therapy.
It is more effective when combined with a team approach with other conservative TMD therapies.
Future Physical Therapy Intervention?
Dr. Rocabado rollback technique Recapturing the articular disc
Interdisciplinary Approach
Dentistry Interventions to TMJD
Occlusal orthotic Beneficial for:
masticatory muscle pain, TMJ pain, TMJ noises, restricted jaw mobility, and TMJ dislocation
If the patient’s pain is limited to the masticatory system with minimal psychosocial contributors, symptoms can be reduced without referral.
Common modes of action for splints All decrease occlusal forces All will have a placebo effect (cognitive awareness) All will alter occlusal contacts
Main Types of Splints
The soft vacuum-formed splint (soft bite guard) Most commonly prescribed splint Good for quick fabrication for emergency TMD Usually made for lower arch Not easily adjustable Worn at night If successful, reproduce symptomatic relief within 6
weeks
Main Types of Splints
The localized occlusal interference splint Indicated for a pt who shows active signs of bruxism
(cheek ridging and tongue scalloping) “The habit breaker” The device restricts the teeth from touching during
closure Forces on the proprioceptive fibers discourage
clenching Effective for patients who parafunction in centric
occlusion Not successful for those who parafunction in extreme
excursive positions Used at night or when pt notices parafunction (ex
driving)
Main Types of Splints
The anterior repositioning splint For disc displacement with reduction Full coverage splint on the lower arch Identified as beneficial if click disappears if
opening/closing from protruded position Guides mandible downward and forward in a protruded
position Theory: If mandible is protruded, condyle is downward
and forward. This temporarily restores normal relationship with the displaced intra-articular disc
Pts wear splints at all times, 24 hours a day -- even when eating
3 months of wear with a careful weaning period
Main Types of Splints
The stabilization splint For patients with facial arthromyalgia where a
discrepancy between centric occlusions and centric relation is the aetiological factor
Names for splint: Tanner appliance, Fox appliance, Michigan splint, centric appliance
Fitted to either the upper for lower jaw The point is to stabilize the mandible against the
maxilla Time consuming to create and can take up to an hour
to fit/adjust Should be word at night
Surgical Modalities
Condylectomy Indicated for fibrous ankylosis Excision of the condyle and removal of fibrous bands which
are restricting the movementsGaparthroplasty
Provides a gap between the glenoid fossa and the ramus of the mandible
Interpositional athroplasty with costochondral graft Creation of a gap and placement of a barrier to maintain
vertical height of the ramusAthroscopyTMJ Replacement
Surgical Interventions
Capsule tightening procedure a. Chemical capsulorrhaphy b. Surgical capsulorrhaphy: Tightening the capsule by
suturesLateral pterygoid myotomyPlication of TM joint ligaments Raising the height of the articular eminence
by down fracture of the zygomatic boneEminectomy and meniscectomy
Surgical Intervention
Arthrocentesis and lavage Has been shown to be an effective technique for the
treatment of acute persistent closed lock of the TMJ Can be done under general anesthesia with two
hypodermic needles Usually the first surgical operation performed Can be helpful if disc is adhered to the bone
When to Refer to PT?
Mechanism Situation
Cervical The patient has neck pain worth of treatment.
The patient has cervicogenic headaches (headaches that can be reproduced by palpating the neck).
Postural The patient has moderate to severe forward head posture.
The patient’s TMD symptoms increase with abnormal postural activities.
The patient desires help in changing poor sleeping posture (e.g., stomach sleeping).
OutcomeOriented
The patient is to have TMJ surgery; patients who receive physical therapy after TMJ surgery may have significantly better results. It is appropriate to refer these patients to PT prior to surgery.
When Does PT Refer to Dentistry?
Time Factor
Event Treatment
Nocturnal The patient awakes with TMD Pain
Improve sleep positions
Occlusal orthotics at night
Prescribe meds that decrease EMG activity
Relaxation prior to sleep
Daytime The patient has symptoms associated with tooth related pain such as
Comprehensive dental examination and treatment
• Pain occurs or intensifies upon drinking hot or cold beverages
• Throbbing pain occurs spontaneously
• Throbbing pain awakes him/her from sleep (there can be other causes for this)
Multidisciplinary Treatment Approach
Orientation Treatment
Relaxation/Stress Management
Breaking daytime parafunction muscle-tensing habits
Learning to relax masticatory muscles and maintaining this relaxed state throughout the day
Learning stress management and coping skills for life’s irritations
Performing biofeedback to help learn to relax masticatory muscles
Orthotic Wearing an occlusal orthotic during the day (as a temporary crutch until daytime habits are broken)
Medicative Prescribing a tricyclic antidepressant that can be taken during the day (e.g. desipramine (25 mg, 1 tab in the morning and afternoon)
Multidisciplinary Treatment Approach Cont.
Orientation Treatment
Medicative Prescribing NSAIDs and/or steroids
Passive Approach Physical therapy modalities (heat, ice, ultrasound, laser, iontophoresis)
Performing jaw-stretching exercises
Active Approach Performing head and neck posture improvement exercises
Indirect Approach
Performing cervical therapist (manual techniques, neuromuscular re-education, etc.)
Questions?
References
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2003). Mindfulness-based Stress Reduction And Health BenefitsA Meta-analysis. Journal of Psychosomatic Research, 57(1), 35-43.
Gray, R., & Davies, S. (2001). Occlusal Splints and Temporomandibular Disorders: Why, When, How? Dental Update, 28, 194-199.
Murakami, K., Hosaka, H., Moriya, Y., Segami, N., & Iizuka, T. (n.d.). Short-term treatment outcome study for the management of temporomandibular joint closed lock. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 80(3), 253-257. Retrieved April 2, 2015, from http://www.oooojournal.net/article/S1079-2104(05)80379-8/abstract
Medeiros Veiga, D., Cunali, R., Bonotto, D., & Afonso Cunali, P. (n.d.). Sleep quality in patients with temporomandibular disorder: A systematic review. Sleep Science, 6(3), 120-124. Retrieved from http://www.sleepscience.com.br/pdf/articles/vol6/SleepScience_vol6_Issue03_art06.pdf
McNeely, M., Olivo, S., & Magee, D. (2006). A systematic review of the effectiveness of physical therapy interventions for tempomandibular disorders. Physical Therapy, 86(5), 710-725.
References
Rocabado, M. (1982). Physical Therapy for the Postsurgical TMJ Patient. Journal of Craniomandibular Disorders: Facial and Oral Pain, 3, 75-82.
TM Joint and Its Diseases. (n.d.). Retrieved April 2, 2015, from http://www.jaypeedigital.com/books/9788180616372/Chapter wise Pdf/10149/Chapter-07_TM Joint and Its Diseases.pdf
Temporo-Mandibular Joint Complex Exercise Suggestions. (n.d.). Retrieved April 2, 2015, from http://www.exodontia.info/files/Temporo-Mandibular_Joint_Complex_Exercise_Suggestions.pdf
Wright, E., & North, S. (2009). Management And Treatment Of Temporomandibular Disorders: A Clinical Perspective. Journal of Manual & Manipulative Therapy, 17(4), 247-254.
Weber, K. (2007, January 1). Standard of Care: Temporomandibular Joint Disorder. Retrieved April 2, 2015, from http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical therapy standards of care and protocols/tmj disorder.pdf