L30 Prac 19-20 TMJ

Question 1

What are 2 characteristics of “before going into the seated position for TMJ assessment you would examine shoulder movements” in observation in PE for TMJ?

Answer 1

1. As this is an adjacent joint region to assess for normal function and
2. To assess neuromuscular control of the shoulder girdle to guide further testing of the muscle system for impairments.

Question 2

What are 4 parts of local (sitting) observation in PE for TMJ?

Answer 2

1. Proportions of the face – 1/3 rule & nose to chin versus nose to outer eye
2. Length of the mandibles
3. Symmetry of condyles – size, position
4. Symmetry of muscles

Question 3

What are 3 initial palpations in PE for TMJ?

Answer 3

1. Temperature
2. Sweating
3. Swelling

All relevant areas – find joint line, palpate over and behind joint, jaw, cheek, temples, forehead, cervical spine

Question 4

What are 8 palpations in PE for TMJ?

Answer 4

1. Temporalis
2. Masseter
3. Medial pterygoid – inside angle of the mandible
4. Anterior belly of digastric
5. Suprahyoid muscles
6. Infrahyoid muscles
7. Intra‐orally – lateral pterygoid
8. SCM, scalenes, UT, Lev scap etc

Question 5

Where are the temporalis and masseter?

Answer 5

Question 6

Where are the lateral and medial pterygoids?

Answer 6

Question 7

Where are the suprahyoid muscles?

Answer 7

Question 8

Where are the infrahyoid muscles?

Answer 8

Question 9

Where are the layers of the cervical muscles?

Answer 9

Question 11

What are 2 steps in the measurement of active movement in PE for the TMJ?

Answer 11

1. In preparation for movement assessment: mark on the bottom front teeth where the gap between the two central front top teeth lines up.
2. Ensure you have reproducible positioning of the Csp
   
   • that is position the patient in sitting supported against a wall with the cervical lordosis supported by a folded/rolled towel

Question 12

What are the steps in the measurement of overbite in PE for the TMJ?

Answer 12

Overbite – with teeth closed, mark on the bottom front teeth where the overlapping central top teeth come down to then measure from this mark up to the top of the bottom teeth with the ruler.

Question 13

What are the steps in the measurement of overjet in PE for the TMJ?

Answer 13

Overjet – with teeth closed, place the ruler back against the bottom front teeth and measure how far forward of this the top centre front teeth are i.e. where they come down onto the ruler.

Question 14

What are 5 characteristics of active movements in PE for the TMJ? What are the 5 movements?

Answer 14

1. Always palpate the joint on each side as the patient performs the movement – repeat 3‐4 times as you:
2. Watch for quality of movement – look for any deviations from the expected normal pathway
3. Feel for timing and symmetry of condylar movement
4. Feel and listen for any noises and note where in range these occur
5. Finally, measure ROM with the ruler and depict on a “T” diagram
6. Opening/closing
7. Protrusion/retrusion
8. Lateral deviation L and R

(remember you would also do upper and lower Csp active movt assessment)

Question 15

What are 6 P/E that can be done in supine for the TMJ?

Answer 15

1. PASSIVE MOVEMENTS
   
   1. Physiological
   2. Accessory
      
      1. longitudinal caud. (distraction)
      2. lateral glide
2. MUSCLE TESTS – static isometric for pain
3. CERVICAL SPINE – PPIVMs,
4. Muscle length – UT, UCE, LS, Scalenes, SCM
5. DNF activation and control
6. LOCAL PALPATION

Question 16

What is the patient’s position, operator’s position and method for the R TMJ longitudinal ↔︎ caudad accessory glide?

Answer 16

• Patient’s Position: Supine lying, head resting on folded towels.
• Operator’s Position: Stand on the (L) side. (L) thumb is placed inside the mouth on the patient’s (R) lower molars. Fingers curl to support mandible in neutral position. (R) hand and forearm support patient’s head, while (R) index finger palpates movement at the (R) TMJ.
• Method: Bracing (R) thumb and wrist and arm, the longitudinal movement is produced by use of body weight.

Question 17

What is the patient’s position, operator’s position and method for the R TMJ lateral → accessory glide?

Answer 17

• Patient’s Position: Supine lying, head resting on folded
• towels.
• Operator’s Position: Stand on patient’s (L) side. (L) thumb is placed inside the patient’s mouth. The ramus of the mandible is lightly gripped between the thumb, from the inside, and the fingers, from the outside. The (R) hand supports the patient’s head.
• Method: A lateral gliding movement of the mandible is produced by stabilising the patient’s head with the (R) hand and moving the (L) arm away from you.

Question 18

What are 2 P/E that can be done in side lying for the TMJ?

Answer 18

Accessory glides:

1. ↓ (PA) glide
2. ← (Medial) glide

Question 19

What is the patient’s position, operator’s position and method for the R TMJ PA ↓ accessory glide?

Answer 19

1. Patient’s Position: (L) side lying, head supported on folded towels. Jaw relaxed from closed position.
2. Operator’s Position: Place pads of thumbs on the posterior surface of the head of the mandible, behind the lobe of the ear. Spread fingers over head and jaw to support thumbs. Walk stand level with TMJ, arms dropped in line with force to move joint PA.
3. Method: Use movement of arms/forearms to produce the postero‐anterior oscillatory movements. Keep thumbs soft.

Question 20

What is the patient’s position, operator’s position and method for the R TMJ medial ← accessory glide?

Answer 20

• Patient’s Position: (L) side lying, head supported on folded towels. Jaw relaxed from closed position.
• Operator’s Position: Place pads of thumbs facing each other over the head of the mandible. This can be accurately found by palpating the TMJ while asking the patient to gently open and close mouth. Spread fingers to provide stability for thumbs.
• Method: Small oscillatory movements are produced by the arms pushing in a medial direction. Do not produce movement by extension of the hand and thumb as this will produce unnecessary tenderness. Can be done with one thumb in contact and the other palpating the joint on the same side or on the under side.

Question 21

What are 7 treatment techniques of TMJ?

Answer 21

1. ↔caud Neutral II, III, IV*
2. ↔caud in an open position IV‐, IV
3. ↔caud with opening – therapist performs opening
4. MWM ↔caud with opening (therapist glides PA and patient performs opening)
5. ↔caud N II in sitting
6. ↔caud with opening in sitting
7. ↔caud with protrusion

Question 22

What is the R TMJ lateral → and medial ← lateral accessory glide? What is the progression for lateral glide and what is the variation for medial glide?

Answer 22

1. → (lateral glide) Neutral II, III, IV
   
   1. Progression eg: → (lateral glide) with lateral deviation (L) II, IV
2. ← (medial glide) N II, III, IV
   
   1. Variations eg: ← (medial glide) with lateral devia􀆟on (R)

Question 23

What is the R TMJ PA ↓ accessory glide? What is the variation for PA glide?

Answer 23

1. ↓ (PA) N II, III
2. ↓ (PA) IV in a mouth open position

• Variations eg:
  
  1. ↓ (PA) with opening – therapist performs opening
  2. MWM of ↓ (PA) with opening (therapist glides PA and patient performs opening)

Question 24

What are the 4 exercise approaches to TMJ conditions? What are the 4 contributing factors that should be addressed?

Answer 24

1. Increasing range, stretches
2. Controlling abnormal movement patterns (mirror)
3. Teaching resting position
4. Strength training (isometric)
5. eg: poor posture,
6. habitual movement patterns
7. Stress behaviours
8. Parafunctional activities