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PHTY3260 EOS > L29: Assessment and treatment of the TMJ > Flashcards

L29: Assessment and treatment of the TMJ Flashcards

1
Q

What are 6 characteristics of TMJ disorders ?

A
  1. Affect 25-33% population, only a small percentage seek treatment
  2. Type of degenerative musculoskeletal disorder
  3. Can occur in association with headache or patients with TMJ problems may have co-existing cervical spine dysfunction
  4. 70% patients with TMJ disorders have malpositioning of the intraarticular disc “internal derangement”
  5. Effectively managed by medical, dental and physiotherapy practitioners
  6. Important to know when to refer to a dentist or specialist physio
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2
Q

What are 3 types of TMJ disorder?

A
  1. Primary TMJ disorder- chronic, traumatic
  2. TMJ pain associated with headache
  3. Headache with a TMJ component
    1. Myogenic dysfunction
    2. Arthogenic disorders
    3. Neurogenic disorder
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3
Q

What are the 5 functions of the TMJ?

A
  1. TMJ function is important for speech, mastication, swallowing, respiration etc.
  2. Having good TMJ function is important for survival
  3. One of the most utilized joints of the human articular system
  4. Highly specialised joint
  5. Part of a complex system
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4
Q

What are 6 characteristics of The Stomatognathic System?

A
  1. Bones: Skull, mandible, hyoid, clavicle and sternum
  2. Joints: Dentoalveolar, TMJs and assoc. ligaments and disc
  3. Muscles
  4. Vascular system
  5. Lymphatic system
  6. Teeth
  • Innervated by the mandibular branch of the trigeminal nerve
  • Intricate neurological controlling system
  • **Close relationship to the Cervical spine**
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5
Q

What are 5 anatomical features of TMJ?

A
  1. Bilateral diarthrodial joint lined with fibrocartilage (Lined with hyaline cartilage?)
  2. 2 separate synovial cavities above and below disc
  3. Intra-articular fibrocartilaginous disc has posterior, intermediate and anterior bands
  4. Posteriorly disc is continuous with bilaminar retrodiscal pad
  5. Anteriorly it is attached to the lateral pterygoid
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6
Q

What is the articular disc in the TMJ? What are 2 parts of articular disc? What are 2 characteristics?

A

Disc continuous posteriorly with a bilaminar RETRODISCAL pad:

  1. SUPERIOR portion – ELASTIC
    • Allowing the mouth to open (stretch)
  2. INFERIOR portion - NON-ELASTIC, provides restraint
    • (Restraints so there sis a limit when opening mouth
  3. Vascular and richly innervated and potential source of pain
    1. Supported by Medial and lateral collateral ligaments – Provide proprioceptive feedback
    2. Restrict disc movement
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7
Q

What are the 2 other structures in the TMJ (apart from the articular disc)?

A
  1. A synovial membrane - lines each compartment
  2. A joint capsule
    1. Anteriorly fuses with the disc
    2. Posteriorly attached to the retrodiscal pad
    3. Reinforced laterally by the lateral TM ligament
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8
Q

What is the nerve supply at the TMJ?

A
  1. Trigeminal nerve (Cr V)
  2. Auriculotemporal nerve
    1. Cranial and cervical nerve supply
    2. Upper 3 cervical nerve roots
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9
Q

Can get _______ associated to TMJ due to nerve connections

A

headache

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10
Q

What are the 2 compartments of TMJ opening and closing?

A
  1. Inferior compartment
    • allows rotation
  2. Superior compartment
    • allows translation
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11
Q

What are the biomechanics of the TMJ?

A

Complex three dimensional combinations of rotational and translational motions

  1. ROTATION - med/lat, AP, longitudinal axes
  2. TRANSLATION - all directions

Occurs in superior joint compartment when disc/ (condyle) glides on the fossa and eminence

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12
Q

What are the 3 active movements of the TMJ?

A
  1. Elevation/depression (opening/ closing)
  2. Protraction (protrusion)/retraction
  3. Lateral displacement
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13
Q

What are the 4 accessory movements of the TMJ?

A
  1. Rotation
  2. Translation
  3. Distraction/compression
  4. Lateral glide
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14
Q

What are 3 phases of TMJ opening biomechanics?

A

Active opening (using muscles)

  1. Anterior rotation
  2. Anterior translation 15mm
  3. Small amount of anterior rotation
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15
Q

What are 2 phases of TMJ closing biomechanics?

A
  1. Movements reversed
  2. Disc pulled back by elastic fibres of retrodiscal pad

Passive recoil (unlike muscular active opening)

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16
Q

What are 3 phases of movements of TMJ?

A
  1. Rotation
    1. Inferior compartment
    2. 0-25mm opening
    3. Limited by horizontal fibres TM ligament
  2. Translation
    1. Superior compartment
    2. 25-40mm opening
    3. Limited by oblique fibres of TM ligament
  3. Rotation
    1. Inferior compartment
    2. 40+mm opening
    3. Limited by SM Ligaments (extra capsular)
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17
Q

What are 3 characteristics of phase 1 of movements of TMJ?

A

Rotation

  1. Inferior compartment
  2. 0-25mm opening
  3. Limited by horizontal fibres TM ligament
    4.
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18
Q

What are 3 characteristics of phase 2 of movements of TMJ?

A

Translation

  1. Superior compartment
  2. 25-40mm opening
  3. Limited by oblique fibres of TM ligament
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19
Q

What are 3 characteristics of phase 3 of movements of TMJ?

A

Rotation

  1. Inferior compartment
  2. 40+mm opening
  3. Limited by SM Ligaments (extra capsular)
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20
Q

What are the 4 main muscles of the TMJ?

A
  1. Temporalis
  2. Masseter
  3. Lateral pterygoids
  4. Medial pterygoids
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21
Q

What are the muscle functions of temporalis of TMJ?

A
  1. All portions
    1. CLOSURE mouth/ELEVATION mandible
  2. Posterior portion
    1. RETRUSION and
    2. LATERAL DEVIATION (to same side)
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22
Q

What are the muscle functions of masseter of TMJ?

A
  1. All parts
    1. ELEVATION
  2. Superficial
    1. PROTRUSION
  3. Deep
    1. RETRACTION with ELEVATION
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23
Q
A
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24
Q

What are the 2 antagonistic parts of lateral ptergoid?

A
  1. SUPERIOR
    1. attaches to disc and condyle
    2. active in CLOSURE to POSITION or STABILISE the disc.
  2. INFERIOR
    1. acting bilaterally produces OPENING, PROTRUSION
    2. acting unilaterally produces LATERAL DEVIATION (to other side)
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25
What are the 2 ways of medial ptergoid?
1. acting bilaterally produces 1. CLOSURE (particularly if in protrusion) 2. PROTRUSION 2. acting unilaterally 1. LATERAL DEVIATION (to opposite side)
26
What are the 4 suprahyoid muscles? Where do the muscles go?
mandible to hyoid bone
27
What are the functions of Digastric and Geniohyoid?
mandibular depression and retrusion
28
What are the functions of Mylohyoid?
depression, tongue muscle
29
What are the functions of Stylohyoid?
swallowing - elevates and retracts hyoid
30
What are 4 muscles of the infrahyoid muscles? What are the functions?
1. Sternohyoid 2. Omohyoid (to scapula) 3. Sternothyroid 4. Thyrohyoid 1. ANATGONISTS to SUPRAHYOIDS * DEPRESS the hyoid, STABILISE 2. Cervical Muscles * STABILISATION in a neutral position
31
What are the layers of cervical muscles?
32
What is the area of pain in the PI for TMJ?
Local TMJ, ear, referred down jaw, face, into head, neck, even to shoulder Nb. Area of pain also for an ear infection, dental condition, similarities with upper cervical joint referral
33
What is the range of motion in the PI for TMJ?
Decreased ROM
34
What are 3 association symptoms in the PI for TMJ?
1. Joint noises - clicking, grating, popping (very common) 2. fullness in the ear, tinnitus 3. dizziness, pins and needles (?C1-2 instability) * Nerve involved pathologies
35
What are 4 aggravating activities in the behaviour of symptoms in the PI for TMJ?
1. chewing, biting (loads other side) 2. low load repetitive activity 3. end of range movement * Keeping mouth open constantly (eg. dental procedures) * Eg, yawning 4. parafunctional activity (eg biting nails, bruxism) * Grinding (eg. can be caused by stress)
36
What are 4 easing activities in the behaviour of symptoms in the PI for TMJ?
1. soft food diet 2. ice, heat, massage 3. medication 4. relaxation, stress avoidance
37
What are 2 AM symptoms in the 24 hour picture in the PI for TMJ?
1. may feel stiff/locked 2. may be painful if grind teeth at night (TMJ splint)
38
What are 2 AM-PM symptoms in the 24 hour picture in the PI for TMJ?
1. may ease as warm up and move 2. pain may increase with loading and activity
39
What is a PM symptom in the 24 hour picture in the PI for TMJ?
may ache if inflammatory
40
What is behaviour of clicking in the PI for TMJ?
* **Hard - discal** dysfunction * **Soft - muscle** in-coordination * Look at timing eg where in opening/closing click occurs, consistency, ? associated with pain.
41
What is hard behaviour of clicking in the PI for TMJ?
Hard - discal dysfunction
42
What is soft behaviour of clicking in the PI for TMJ?
Soft - muscle in-coordination * Hypermobile
43
When does the TMJ click?
opening/closing or lateral deviation
44
What is the history in the PI for TMJ?
* ONSET - Insidious, traumatic? * COURSE - Stage * Stable or progressive * ASSOCIATED SYMTOMS – onset, changes * RELATED AREAS - Cervical, Dental, Head * PAST EPISODES, TREATMENT? Effect?
45
What is the general posture observation in the PE for TMJ?
* **General posture** * Partic. craniocervical posture * FHP influences mouth opening * Upper quarter * **Particularly cervical spine – head on neck and Csp / Tsp / scapular posture**
46
What is the 2 main local observation in the PE for TMJ?
***Upright postural position of the mandible (UPPM)*** **Resting position** 1. At “rest” there is a 2-5mm gap between the upper and lower teeth – “freeway space” 2. **Occlusal position** – teeth are maximally intercuspated – centric occlusion
47
What is the 5 parts of local observations in the PE for TMJ?
asymmetry, increased muscle tone 1. Proportions of the face – 1/3 rule 2. Compare nose to chin versus nose to outer eye 3. Length of the mandibles 4. Symmetry of condyles – size, position 5. Symmetry of muscle bulk, tension
48
What is the 3 parts of initial palpation in the PE for TMJ?
1. Temperature 2. Sweating 3. Swelling All relevant areas – over and behind joint, jaw, cheek, temples, forehead, cervical spine Main muscles or muscle groups Red mark behind ear --\> common indication for mastoiditis
49
What are the opening active movements in the PE for TMJ?
about 45mm (up to 55mm) 1. Initial rotation – (inferior joint) 1. condylar ridge moves forward on the intermediate zone of the disc 2. Disc rotates backward on condyle 2. Translational phase – (superior joint) 1. disc and condyle move together down the articular eminence Keep tongue on roof of mouth to feel rotation phase, then release and open mouth fully, feel translation phase
50
What are the closing active movements in the PE for TMJ?
Closing – the reverse sequence
51
What are the protrusion active movements in the PE for TMJ?
5mm Almost purely translation 1. superior joint 2. discs and condyles glide forward together
52
What are the retrusion/retraction active movements in the PE for TMJ?
3mm 1. Translation – superior joint 2. Close packed position of the joint
53
What are the lateral deviation active movements in the PE for TMJ?
(L) and (R) – 7-9mm (12?) Going to the (L) 1. the right disc & condyle move/ translate forward, inferior and medial 2. the left disc & condyle pivot/ moving posteriorly
54
What are the 2 loading tests in the PE for TMJ?
1. Posterior loading 2. Superior loading
55
What are the 2 main passive movements in the PE for TMJ?
1. Physiological - all 2. Accessory 1. longitudinal caud. (distraction) 2. lateral glide 3. postero-anterior glide 4. medial glide
56
What are the 5 physiological passive movements in the PE for TMJ?
1. Opening 2. Closing 3. Protrusion 4. Retrusion /retraction
57
What are the 4 accessory passive movements in the PE for TMJ?
1. longitudinal caud. (distraction) 2. lateral glide 3. postero-anterior glide 4. medial glide
58
What is the longitudinal caudad (↔︎) accessory passive movements in the PE for TMJ?
Along teeth inside mouth or outside on mandible * Most useful (pain relieving)
59
What is the lateral glide (→) accessory passive movements in the PE for TMJ?
External over opposite condyle or internal on mandible * Can be for hypomobility
60
What is the PA glide (↓) accessory passive movements in the PE for TMJ?
Using condyle (unilateral) * Problem with translation phase
61
What is the medial glide (←) accessory passive movements in the PE for TMJ?
External over condyle * Lateral glide on contralateral side
62
What are 9 causes of pain in TMJ?
1. Developmental abnormalities 2. Hypermobility 3. Occlusal problems 4. Trauma – macro (dislocation), micro/ repetitive (Damage to disc (unable to be regenerate)) 5. Post surgery/post bracing 6. Systemic diseases 7. Myofascial pain dysfunction 8. Disc dysfunction /derangements 9. Postural, cervical spine, tension/psychological
63
What are 4 examples of TMJ internal derangement?
1. Minor disc dysfunction - single click 2. Anterior disc displacement with reduction - reciprocal clicks 3. Anterior disc displacement without reduction/ Closed lock 4. Open lock
64
What is mild disc dysfunction (single click)?
65
What is an anterior disc displacement with reduction?
66
What is an anterior disc displacement without reduction?
67
What are 5 manipulative therapy in the management of TMJ movement impairment?
1. Restore movement 2. Relieve pain 3. Stretch tight structures 4. Increase range of movement 5. Create environment to promote healing
68
What are 5 treatment approaches of TMJ?
1. Multi-disciplinary 2. Multi-modal 3. For local problem treat impairments 4. Treat any Csp signs and see effect/relationship 5. TMD can be considered a chronic pain condition
69
What 7 multi-disciplinary approach for TMJ?
1. Dentist 2. Orthodontist 3. Prosthodontist (Splint) 4. Endodontist 5. Oral and Maxillofacial Surgeon 6. Periodontist 7. Physios specialised in TMJ treatment
70
What are 8 pain treatment for TMJ?
1. Education and advice 2. **Teach resting position of mandible** 3. Manual therapy 4. Postural correction 5. EPAs: Heat,Ice, US, Laser, TENS 6. Exercise – ROM, proprioceptive, movt patterns 7. Splinting 8. Stress management/relaxation
71
What are 3 disc dysfunction treatment for TMJ?
1. Mobilise in position of normal relationship between disc and condyle 2. Aim for stability of disc – proprioceptive exercises, stability exercises 3. Postural re-education, treatment of imbalances in the muscle system, muscle impairments
72
What are 3 stiffness treatment for TMJ?
1. End of range mobilisation – IV, combined techniques, MWMs 2. Stretches combined with heat/ice 3. Exercises – gain range, movt patterns
73
What are 4 muscle spasm treatment for TMJ?
1. Mobilisation – sustained IV 2. Massage/Relaxation 3. Contract/relax 4. EPAs
74
What is the TUTALC as the resting position of mandible/TMJ?
1. Tongue up 2. Teeth apart 3. Lips closed Can use this as a control position of mandible in hypermobile patients
75
What are 5 exercises/HEP for TMJ?
1. Increasing range, stretches 2. Controlling abnormal movement patterns (mirror) 3. Teaching resting position 4. Strength training (isometric) 5. Addressing contributing factors eg: poor posture, habitual movement patterns 6. Stress behaviours 7. Parafunctional activities

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