8b TMJ

Question 1

TMJ anatomy

Answer 1

Insertion of condyle of mandible into mandibular fossa of
temporal bone.
A synovial, condylar, and modified ovoid hinged joint with
fibrocartilage joint surface.
An articular disc completely divides each joint into two cavities

Question 2

What are the two movements of TMJ

Answer 2

rotation and gliding

Question 3

When does rotation occur at TMJ

Answer 3

Rotation -from beginning of movement to mid-range movement
Upper head of lateral pterygoid muscles pulls the disc anteriorly
and prepares for condylar rotation - through two condylar heads
Disc provides congruent contours

Question 4

When does gliding occur at TMJ

Answer 4

Gliding – the 2nd movement – a translatory movement
of condyle and disc along the slope articular surface
Both essential for full mouth opening and closing

Question 5

Resting position TMJ

Answer 5

Resting position – TUTALC (tongue up, teeth apart, lips

closed)

Question 6

Loose packed positiong TMJ

Answer 6

Loose packed position -Slightly open, teeth apart, tongue up

Question 7

Restricted capsular pattern TMJ

Answer 7

Restricted capsular pattern -reduced opening and protraction

OR If unilateral mandible deviates to one side

Question 8

Close packed positiong

Answer 8

Close packed position – Mouth closed, teeth tightly clenched

Question 9

Movements upper cavity TMJ

Answer 9

• Upper cavity - gliding, translation, sliding

Question 10

Movements lower cavity TMJ

Answer 10

Lower cavity – rotation and then hinge movement

Question 11

Area of pain TMJ

Answer 11

• Area of pain: Pain over the TMJ joint

* In or around the ear

Question 12

Muscles that could be sore TMJ

Answer 12

• +/- Soreness of facial mms: masseter and

temporalis

Question 13

TMJ Specific Patient History

Answer 13

• Any pain /restriction in opening or closing mouth?
• Any pain with eating ?
• Does the patient chew on the right or left side? ( malocclusion)
• Which jaw movements cause pain?
• Do symptoms change over 24 hours? (OA)
• Provoking activities – yawning, biting, chewing, swallowing,
speaking, shouting ?
• Dos the patient breathe through nose or mouth?
• Any clicking/crepitus of the jaw ?
• Has the mouth or jaw ever locked?
• Doe the patient have any habits - smoking a pipe, leaning on
chin, chewing gum, hair, pursing and chewing lips, biting nails,
other nervous habits? – all place additional stress on TMJ
• Does the patient grind or tightly clench their teeth? (=
bruxism)
• Any related psychosocial problems ?
• Are there any teeth missing? ( deviation )
• Any teeth sensitive – indicative of tooth decay
• Any difficulty swallowing ?

Question 14

Special questions TMJ patient interview

Answer 14

• Any thumb sucking?
• Any ear problems – hearing loss, ringing in ears, blocking,
dizziness?
• Any habitual head posture?
• Any voice changes? – may indicate muscle spasm
• Any headaches?
• Has patient had any recent dental work?
• Does the patient wear a dental plate?

Question 15

P/E TMJ

Answer 15

• Observation: posture (poke chin)
• Active ROM (add OP)
• Resisted isometric movements
• Palpation
• Passive ROM of mandible
• Passive joint mobilisations

Question 16

Observations TMJ

Answer 16

• Posture of head and neck (poke chin)
• Facial symmetry – horizontal and vertical
• Vertical should be in thirds –
– hair line to bipupital line
– bipupital line to nose
– nose to chin
Any paralysis ?
Normal teeth alignment?
• Any mal-occlusion - a major cause TMJ disc problems

Question 17

Note occlusal position

Answer 17

• Class 1 occlusion = normal antero-posterior alignmemt of
maxillary teeth to mandibular teeth
• Class 2 – malocclusion – overbite of mandibular on maxillary
• Class 111 malocclusion – underbite of mandibular relative to
maxillary

Question 18

AROM TMJ

Answer 18

Ch eck Cervical AROM – should have full ROM while keeping
mouth closed
• Flexion – mandible moves up / anterior; posterior neck
structures tight
• Extension - mandible down and back; anterior neck
structures tight
TMJ AROM (move to pain or move to limit)
• Opening /closing mouth (depression/elevation)
• Protrusion (protraction) / retrusion (retraction) mandible
• Lateral deviation of mandible left and right

Question 19

How much TMJ opening do you need for normal acitivity

Answer 19

Need 25-35 mm for normal activity

Question 20

Normal opening

Answer 20

Normal opening –should be straight line – and 35-

60mm ( 2-3 finger widths in mouth )

Question 21

Normal lateral deviation TMJ

Answer 21

Lateral deviation – normal 10-15 mm

Question 22

Normal protrusion -

Answer 22

normal >7mm

Question 23

Normal retrusion (retraction)

Answer 23

Retrusion (retraction)- normal 3-4mm

Question 24

Muscles: Elevators (closes mouth)

Answer 24

• Temporalis Elevators (closes mouth)
• Masseter Elevators (closes mouth)
• Medial pterygoid Elevators (closes mouth)

Question 25

Muscles: Depressors (opens mouth)

Answer 25

* Lateral pterygoid Depressors (opens) | * Digastric Depressors (opens)

Question 26

Suprahyoids action

Answer 26

• Suprahyoids - influence jaw position, tongue | mobility, speech, swallowing

Question 27

Infrahyoids actition

Answer 27

• Infrahyoids - stabilise hyoid bone

Question 28

Nerve supply TMJ joint

Answer 28

• Supplied by both cranial and cervical nerves • CR V (trigeminal n) – Nb. Muscle weakness may signal an UMN problem

Question 29

Auriculotemporal nerve

Answer 29

• Auriculotemporal nerve – Also supplies posterior capsule and blood vessels, rertodiscal pad, typanice membrane, external auditory meatus, tragus – Could give rise to symptoms such as tinnitus, dizziness, hearing problems

Question 30

Resisted isometric movements TMJ

Answer 30

• Resisted isometric movements – Resisted opening – depression – Resisted closing – elevation or occlusion – Resisted lateral deviation

Question 31

Reflexes TMJ

Answer 31

Reflexes ( jaw reflex test for cranial nerve V ) and cutaneous distribution. Know the dermatomes.

Question 32

Palpation TMJ

Answer 32

``` • Through external meatus Feel for: • Smooth movement • Equal opening R and L • Then place fingers over mandibular condyles – pain, tenderness • Palpate mandible along entire length • Hyoid / thyroid ```

Question 33

Accessory/Joint Play Movements TMJ

Answer 33

* Longitudinal cephalad * Longitudinal caudad (within the patient’s mouth) * Lateral glide mandible (within the patient’s mouth) * Medial glide of mandible (transverse) * Posterior glide of mandible * Anterior glide of the mandible

Question 34

Treatment Modalities TMJ

Answer 34

* Soft tissue massage – masseter / temporalis * Joint mobilisations * Movement pattern retraining * Neuromuscular control * Posture retraining * Review patient habits – chewing gum, leaning on hand * Workplace set up * Relaxation techniques * Dental referral – splints,

Question 35

MWM TMJ

Answer 35

``` • Anterior/inf translation of the mandible along the joint line and correct deviation as the patient opens the jaw. Pt can add OP. • 3 times reassessed. Then 3 sets of 6. ```

Question 36

Four common conditions presenting | to physiotherapy TMJ

Answer 36

* Hypomobility * Hypermobility * Disc derangement * Myofascial pain

Question 37

Causes Hypomobility TMJ

Answer 37

``` Causes: • Disc derangement • Arthritis • Inflammation • Joint effusion • Myofascial pain • Muscle spasm • 2° to parafunctional habits ```

Question 38

Treatment hypomobility TMJ

Answer 38

``` Treatment: • Joint mobilisation • Active exercise • Passive stretching • Exercises for muscle relaxation using mirror for biofeedback • Correct muscle imbalance • Posture correction ```

Question 39

Causes hypermobility TMJ

Answer 39

``` Causes: • Lax capsule and ligs • Systemic hypermobility • Disc displacement • OA • Psychiatric disorders • Parafunctional habits eg. prolonged bottle feeding, thumb sucking, dummy use in children • Habitual wide opening of mouth ```

Question 40

Treatment hypermobility TMJ

Answer 40

``` Treatment: • Jaw control, • tongue on roof of mouth while opening, guide movement of mandible, control anterior translation • Use of mirror for biofeedback • Posture correction • Concentric/eccentric exercise • Isometric exercise ```

Question 41

Causes disc dereangement TMJ

Answer 41

``` Causes: • Mal-occlusion - condyle displaces post during closing • Trauma – partial tear of disc from capsule • Excessive pressure - from clenching or trauma • Incoordination of pterygoids - so disc snaps over condyle on opening • Degeneration • Stretching of ligaments – eg. by frequent subluxation ```

Question 42

Treatment disc derangement TMJ

Answer 42

``` Treatment: • Locked jaw: • distract mandible away from opposing joint surface, thumb inside mouth • Avoidance of exacerbating factors • Heat • Soft diet • Surgery ```

Question 43

Causes myofacial pain TMJ

Answer 43

``` No organic disease or joint derangement • Dull ache unilaterally • H/A and neck pn • Aggravated by chewing, tension • May be present on waking (night bruxism (grinding)) • Symptoms diffuse • Jaw stiffness • Muscles tender ```

Question 44

Treatment myofascial pain TMJ

Answer 44

Treatment: • Stretch, mobilisation • Relaxation (TUTALC) • Dental splint

Question 45

Causes dislocation of TMJ

Answer 45

 Yawning or taking a large bite,  Excessive contraction of the lateral pterygoids  Heads of the mandible to dislocate anteriorly  (pass anterior to the articular tubercles).  Mandible remains wide open and unable to close  A sideways blow to the chin when the mouth is open dislocates the TMJ on the side that received the blow.

Question 46

Arthritis of TMJ

Answer 46

 TMJ may become inflamed from the degenerative arthritis  Abnormal function of the TMJ may result in structural problems  Dental occlusion and joint clicking (crepitus).  The clicking is thought to result from delayed anterior disc movement during mandibular depression and elevation  Adhesions  Breakdown of cartilage