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Ortho 3 > TMD > Flashcards

TMD Flashcards

0
Q

TMJ - Roles

A 
Functional activities:
-Mastication
-Communication 
-Yawning
-Laughing
Parafunctional activities:
-Bruxism (grinding of teeth)
-Chewing pencils 
(talking involves 6,000 motions minimum)
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1
Q

Semantics

A
  • TMJ = temporomandibular joint

- TMD = temporomandibular disorders

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2
Q

TMJ Anatomy - Overview

A
  • Diarthrodial synovial joints
  • Fibrous cartilage covers articular surfaces
  • Fibrocartilaginous articular disc
  • Construction: beneficial for rapid and smooth mandibular movement; vulnerable to failure (too little loading, too much loading)
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3
Q

TMD Described

A

Any dysfunction involving the temporomandibular joint(s)
-Soft tissue
-Capsule
-Meniscus/disc
-Bone
(all structures have to work together for function)

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4
Q

Anatomical Bony Review

A

Osseous structures

  • Temporomandibular joint
  • Zygomatic arch
  • Mastoid process
  • Mandible
  • Hyoid
  • C1
  • C2
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5
Q

Anatomical Joint Review

A
  • superior lamina
  • meniscus
  • inferior lamina
  • retrodiscal pad
  • articulating surface on the condyle
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6
Q

Anatomical Soft Tissue Review

A
  • Masseter - sitting, supine, clenched, relaxed (elevates mandible or closes the mouth)
  • Temporalis - sitting, supine, clenched, relaxed
  • Sternocleidomastoid - sitting, supine (rotates head to opposite side, together-FL)
  • Suprahyoid muscles - sitting, supine
  • Infrahyoid muscles - sitting, supine (stretch weakness with FHP)
  • Suboccipital muscles - supine
  • Scaleni muscles - supine
  • Pectoralis major & minor muscles
  • Latissimus dorsi muscles
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7
Q

Anatomical Neurogenic Review

A
  • facial nerve and trigeminal nerve

- sharp electrical current in the face

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8
Q

Biomechanics of TMJ - Overview

A
  • Ginglymoarthrodial articulation (simple hinge joint)
  • Osteokinematics:
  • Depression
  • Protrusion
  • Lateral Excursion
  • Arthrokinematics:
  • Rolling & Spinning
  • Distraction
  • Anterior translation
  • Lateral glide
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9
Q

Biomechanics - Depression

A
  • Opening of mouth in sagittal plane
  • Normal range 40 mm
  • First two knuckles in mouth = 20 to 25 mm (functional, but not normal)
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10
Q

Biomechanics - Protrusion

A
  • Movement of mandibular condyles in horizontal plane
  • Lower incisors should at least meet upper incisors, ideally should move past by several mm
  • Measure with ruler from superior teeth to inferior teeth
  • Allows formation of sounds (His, church, house, etc)
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11
Q

Biomechanics - Lateral Excursion

A
  • Mandible moves laterally in horizontal plane (left and right)
  • Normal lateral excursion = 8 mm
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12
Q

Biomechanics - Deviation

A
  • “S” curve
  • Mandible moves away from midline during mandibular depression or protrusion
  • Mandible returns to midline by end of movement
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13
Q

Biomechanics - Deflection

A
  • “C” curve
  • Mandible moves away from midline during mandibular depression or protrusion
  • Mandible does NOT return to midline
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14
Q

NOTE Biomechanics

A
  • Deviation or deflection may be a result of anomalies of the osseous structures
  • In presence of good functional movement, may be considered insignificant and require no intervention
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15
Q

Biomechanics - Mandibular Depression - Phase 1

A
  • Rotation of condyle first 10 to 15 mm
  • Condyle is convex on concave
  • Rotation is posterior in relation to temporal bone
  • After first 11 mm, condylar head translates anteriorly to achieve full functional opening
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16
Q

Biomechanics - Mandibular Depression - Phase 2

A

-Accessory movement and anterior translation of condyle
-Starts at 10 to 15 mm of mandibular opening in conjunction with continued rotation to functional opening = 40 mm
-If translation is severely restricted, 20 to 25 mm of opening can still be achieved by rotation alone
(have to have anterior translation for full mandibular depression)

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17
Q

Biomechanics - Protrusion

A
  • Accessory movement of bilateral anterior condylar translation
  • Anterior translation of mandibular condyles in horizontal plane
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18
Q

Biomechanics - Lateral Excursion

A

-Contralateral slide - accessory movement of of anterior translation
-Ipsilateral side - accessory movement of spin
(L lateral excursion limited, R problem, R lateral excursion not limited)

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19
Q

Note Capsular or Intracapsular Problems

A 
Restrictions:
-Translation - primary movement restricted, most difficult to restore
-Distraction
-Lateral glide 
(rolling, spinning - never the problem)
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20
Q

Biomechanics - Disc relationship to condylar head

A

Initial Opening
-First 10 mm disc remains stationary
-Condyles rotate
Mid to complete opening
-Disc and mandibular condyle translate anteriorly relative to eminence of temporal bone
-Disc pulled into posterior rotation by superior stratum

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21
Q

Dental Referral

A
  • Written referral
  • Diagnosis - specifics
  • Imaging
  • Precautions
  • Dental procedures performed
  • Medications prescribed (anti-depressants common)
  • Other (HA very common)
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22
Q

PT for TMD Examination & Intervention

A
  • Client history
  • Systems screen - differential diagnosis
  • Musculoskeletal examination
  • Manual therapy techniques
  • Exercises
  • Modalities
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23
Q

Patient History

A
  • Cardinal symptoms related to TMD (according to Steven Kraus): Symptoms located in preauricular area (front of ear) with or without reference into temporal or mandibular areas; Symptoms reproduced, increased, or decreased with functional activities or parafunctional activities of mandible
  • Symptoms consist of one or combination of: Pain/discomfort; Joint noises during jaw movements; Limited or difficult jaw movements
  • Onset, frequency, duration, & intensity of symptoms determine irritability & progression of disorder
  • Document what increases and/or decreases symptoms for reassessment
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24
Q

Objective Evaluation

A 
Systems screen - differential diagnosis
-Neurological issues
-Cervical spine & upper quarter
-Dental screening
Musculoskeletal examination 
-Postural examination:  alignment, symmetry
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25
Q

Differential Diagnosis

A
  • Migraine headaches
  • Cervicogenic headaches
  • Trigeminal neuralgia
  • Temporomandibular dysfunction
  • Spine disorder: Postural dysfunction; Facet joint disorder; Intervertebral disc disorder
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26
Q

Optimal Posture in Standing

A
  • Postural muscles constantly active
  • Optimal line of gravity:
  • Through external auditory meatus
  • Through the midline of the trunk
  • Through the greater trochanter
  • Anterior to midline of knee
  • Anterior to lateral malleolus
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27
Q

Symptoms Associated with Spinal Dysfunction

A
  • Headaches: Tension, Migraines
  • Facial pain
  • Neck & back pain
  • Extremity symptoms: Radicular pain, Numbness & tingling
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28
Q

Neck & Orofacial Pain

A
  • Evidence of association between cervical spine, stomatognathic system, & craniofascial pain
  • 85% of patients seeking care at an Orofacial Pain Clinic (n=283) had cervical muscle tenderness
  • 49% had moderate to severe
  • 76% of pts with cervical muscle pain had diagnosis of masticatory myalgia
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29
Q

Pain in the Neck

A
  • One adult sample, 54% had neck pain in last 6 months
  • Economic costs second only to LBP in worker’s comp in US
  • 25% of diagnoses among patients receiving outpatient PT
  • More prevalent in a sample of people with TMD than in people without TMD
30
Q

Theoretical Basis for the Relationship between Cervical Disorders and Orofacial Pain

A
  • The literature provides a strong rationale for investigating cervical disorders in clinics seeing patients with orofacial pain.
  • Convergence of cervical sensory information onto the trigeminal system in the trigeninocervical nucleus.
  • Neurophysiologic potentiation between masticatory & cervical muscles.
  • Neck pain results in increased parafunction = adverse effects on TMJ.
31
Q

Cycle of Pain and Dysfunction

A
  • Muscular overload, postural strain –> abnormal electrical activity in the muscle –> sustained contraction, muscle tension –> reduced blood flow to and within the muscle –> muscle pain –> abnormal electrical activity in the muscle (loop continues)
  • if you don’t interrupt at muscle pain: muscle pain –> unbalanced postures –> joint pain –> abnormal joint movement –> muscle pain (loop continues)
32
Q

Physical Therapy Examination

A
  • Joint motion - observations & measurements (ROM)
  • Joint loading
  • Accessory motions
  • Soft tissue: Muscular strength, Muscular flexibility, Palpation (Muscle spasms, trigger points, tenderness)
33
Q

Exam - Mandibular Depression

A

(Measure with patient in good postural alignment (compare to patient’s normal posture))

  • Opening in sagittal plane
  • Measure between superior & inferior central incisor space
  • Functional (ability to eat) = 25 to 30 mm
  • Ideal = > or = 40 mm
34
Q

Exam - Lateral Excursion

A
  • Horizontal plane
  • Measure from superior central incisor space to inferior central incisor space
  • Functional = canine to canine
  • Ideal = symmetry, past the canine several mm
35
Q

Exam - Protrusion

A
  • Horizontal plane
  • Functional
  • -Edge to edge of central incisors
  • Ideally
  • -Inferior teeth should move past superior teeth by several mm
36
Q

Exam - Palpation

A

(sitting and supine)

  • Masseters
  • Temporalis
  • Suprahyoid
  • Infrahyoid
  • Sternocleidomastoids
  • Scaleni
  • Suboccipitals
  • Hyoid
  • Trachea
  • Joint
37
Q

Exam - Intraoral Musculature - Pterygoids (Lateral)

A
  • Palpate buccal (outside) border of upper molars
  • Slide fingers towards mandibular head as far as possible
  • Tilt fingers in posterior superior direction & palpate anterior medial pterygoid covering fibers of lateral pterygoid
38
Q

Exam - Intraoral Musculature - Pterygoids (Medial)

A
  • Place index finger below tongue towards angle of mandible
  • Other index finger on external mandibular angle
  • Intraoral palpating finger examines inferior point of insertion of medial pterygoid
39
Q

Exam - Intraoral Musculature - Occlusion

A
  • Look at teeth & how fit together

- People do what is necessary to chew food & this affects the joints

40
Q

Exam - Joint Loading - Dynamic Loading & Distraction

A
  • Selective test involving either compression (loading) or distraction
  • Unilateral resistance placed between upper & lower third molars
  • -Ipsilateral side - distraction of condyle
  • -Contalateral side - compression
41
Q

Exam - Joint Loading - Passive Loading

A
  • Muscles relaxed with back teeth slightly apart
  • Grasp chin with index finger & thumb
  • Apply pressure to mandible posterior superior & to right & left
  • Counterforce on back of head
42
Q

Exam - Accessory Motion

A
  • Intraoral distraction
  • Intraoral gliding
  • Intraoral sliding
  • Hyoid swallow
43
Q

Specific Diagnoses

A
  • Inflammatory conditions
  • -Capsulitis
  • -Synovitis
  • Capsular fibrosis
  • Osseous mobility conditions
  • Articular disc displacement conditions
44
Q

Inflammatory Conditions - Patient Complaints

A
  • Pain/discomfort located in preauricular area
  • Pain/discomfort produced, increased, or decreased with functional or parafunctional activities
  • Pain on ipsilateral side with back teeth together
  • Limited opening
  • Pain/discomfort decreased, or at least not aggravated by rest
45
Q

Inflammatory Conditions - Palpation

A
  • Lateral to lateral pole of condyle
  • > Palpate lateral pole with back teeth touching
  • > Reproduction of symptoms on ipsilateral side indicates capsulitis
  • Posterior & lateral to lateral pole
  • > Open mandible to 30 mm
  • > Palpate condylar head & area
  • > Reproduction of symptoms on ipsilateral side indicates capsulitis
  • External auditory meatus (EAM)
  • > Mandible open
  • > Place 5th digit in patient’s EAM
  • > Apply slight pressure forward
  • > Have patient bring back teeth together
  • > Reproduction or an increase of symptoms on ipsilateral side indicates synovitis
  • > Do not be concerned about any noises
46
Q

Inflammatory Conditions - Dynamic Loading & Distraction

A
  • Patient bites on unilateral resistance placed between upper & lower third molars
  • Ipsilateral side - distraction
  • Contralateral side - compression
  • Palpate lateral & posterior to lateral pole, if reproduces symptoms = capsulitis
  • Palpate EAM - if only test that reproduces symptoms = synovitis
47
Q

Inflammatory Conditions - Passive Loading (retrusive compression)

A
  • Muscles relaxed with back teeth apart
  • Grasp patient’s chin with index finger & thumb
  • Apply pressure to mandible posterosuperior & to right & left
  • Counterforce on back of patient’s head
  • Reproduction or increase of symptoms suggests either capsulitis or synovitis
48
Q

Inflammatory Conditions - Mandibular Dynamics

A
  • Not reliable for inflammatory conditions

- May appear normal

49
Q

Capsular Fibrosis - Patient Complaints

A

(usually direct result of chronic capsulitis)

  • Patient history is key to diagnosis
  • Usually painless unless force is used during mandibular dynamics to cause injury or overextension of capsule
  • Long-term history of capsulitis
  • Prolonged immobilization
  • Trauma
  • Arthritis
50
Q

Capsular Fibrosis - Physical Exam

A
  • Osteokinematic movements limited or altered

- Suggests decrease in arthrokinematic movement of translation on involved side

51
Q

Osseous Mobility Conditions - Hypermobility

A
  • Usually asymptomatic
  • Occurs frequently in patient & non-patient population
  • Hypermobility scale
52
Q

Osseous Mobility Conditions - Hypermobility - Patient Complaints

A
  • Subjective statement
  • -“My jaw feels like it goes out of place.”
  • Noted with eating thick sandwich or yawning
  • Report of joint noises
  • Short term episodes of jaw catching in fully opened position - prevents closure of mouth
53
Q

Osseous Mobility Conditions - Hypermobility - Physical Exam

A
  • Examine while patient performs active mandibular depression
  • Palpate lateral pole
  • -Reveals larger than expected indentation posterior with excessive anterior movement
  • Deflection of mandible towards contralateral side of involved joint at end of opening with unilateral hypermobility
54
Q

Osseous Mobility Conditions - Hypermobility - Physical Examination

A
  • Palpable irregularities at end of mandibular depression & beginning of mandibular closure
  • -These are joint noises
  • -May or may not be able to hear noises, but can be felt
  • Mandibular depression > 40 mm
55
Q

Osseous Mobility Conditions - Dislocation

A
  • History & clinical findings are same as hypermobility
  • May not be painful
  • Patient presentation
  • > Mouth fully open
  • > Mouth deflected towards contralateral side of involved joint
  • > Inability to close mouth
  • Condyle & disc have translated well beyond articular crest onto tubercle & are stuck
56
Q

Articular Disc Displacement Conditions - Disc Displacement with Reduction (DDWR) - Patient Symptoms

A
  • Joint noise during mandibular opening & closing
  • Two “pops” or “clicks”
  • > One on opening
  • > Second on closing
57
Q

Articular Disc Displacement Conditions - DDWR - Physical Exam

A
  • reciprocal click
  • Palpation over lateral poles reveals opening click (reduction of disc) & closing click (disc displacing anterior to condyle)
  • Reciprocal click occurring at different mandibular positions
  • Opening noise loudest, closing noise softest
  • Clinician places fingertips under angle of mandible bilaterally & lifts anterosuperiorly as patient opens & closes mandible
  • > Preload joint to enhance loudness of reciprocal click, especially closing click
  • > Loading joint during movement often will increase or reproduce pain if related to DDWR
  • Have patient open to produce opening click, then close forward bringing upper & lower anterior central incisors together end-to-end
  • > From forward position, have patient open & close as wide as possible
  • > Palpate over lateral poles
  • > Large percentage reciprocal clicks with cease to exist
58
Q

Note - Reciprocal Click

A
  • If a reciprocal click is not present, a DDWR is not present
  • No need to proceed to next 2 tests
  • Purpose of these tests is to confirm that reciprocal click is related to a DDWR
59
Q

Articular Disc Displacement Conditions - Disc Displacement without Reduction (DDWoR) - acute - Patient Symptoms

A
  • Used have joint noises & previous episodes of intermittent locking
  • Joint noises have ceased
  • Inability to open mouth wide
  • Difficulty performing functional jaw movements
  • > Chewing, talking, yawning
60
Q

Articular Disc Displacement Conditions - DDWoR - acute - Physical Exam

A
  • Mandibular dynamics
  • > Depression
  • —>Opening limited to 20 to 25 mm
  • —>Deflection toward ipsilateral side
  • > Protrusion
  • —>Limited
  • —>Deflection toward ipsilateral side
  • > Lateral excursion
  • —>Limited toward contralateral side
  • No palpable irregularities noted with DDWoR
61
Q

Articular Disc Displacement Conditions - DDWoR - chronic - Patient Symptoms

A
  • History similar to DDWoR
  • Progressed to DDWoR
  • No limitation in jaw movements
  • Describes hearing noises
  • > Crepitus with jaw movements
62
Q

Articular Disc Displacement Conditions - DDWoR - chronic - Physical Exam

A
  • Mandibular Dynamics
  • > Depression
  • —>Functional or close to functional
  • —>Minimal deflection toward ipsilateral side toward end of opening
  • > Protrusion
  • —>Functional or close to functional
  • —>Minimal deflection toward ipsilateral side toward end of protrusion
  • > Lateral excursion
  • —>Functional or close to functional toward contralateral side
  • > Palpation
  • —>Irregularities of crepitus
63
Q

Physical Therapy Intervention - Key

A
  • Key - restore function
  • Restore rest position of joint
  • > Rocabado 6X6 exercises
  • —>Tip of tongue on roof of mouth just behind upper teeth, muscles relaxed, teeth apart
  • —>Chest out - pulls head back
  • —>Upper cervical flexion 15 degrees - straightens cervical spine, more may cause discogenic problem in cervical spine
  • —>Diaphragmatic breathing
64
Q

PT Intervention - Patient Education

A
  • Rest joint, if inflamed must allow inflammation to calm down
  • Soft diet
  • Minimal chewing - no gum
  • No heavy kissing
  • No wide opening - large sandwich, apple
  • Nasal breathing
  • Yawning
  • Sleep supine
  • No caffeine
  • No tobacco
65
Q

PT Intervention - What to Address?

A
  • Address posture
  • > Forward head posture
  • > Headaches
  • Address soft tissue
  • > Flexibility of upper quarter
  • > Muscle imbalance - strength
  • > Muscle spasms and guarding
  • > Capsular tightness
  • > Scar tissue
  • > Motor control
66
Q

PT Interventions

A
  • Posture correction
  • > Stretch tight structures
  • > Strengthen weak structures
  • Manual therapy
  • > Soft tissue mobilization
  • —>Anterior & posterior neck
  • —>Upper quarter
  • > C-spine mobilization
  • Aerobic exercise
67
Q

PT Interventions - TM Manual Intraoral Techniques

A
  • Used to restore functional mandibular dynamics regardless of disc position
  • Combination of distraction or translation
  • Distraction - acute DDWoR or capsular fibrosis
  • Distraction with translation
  • Lateral glide - capsular fibrosis
68
Q

PT Interventions - Modalities

A
  • Ultrasound
  • > Intensity 0.5 w/cm^2, pulsed, 3.3 MHz, 5 minutes with patient pumping/flushing joint to nourish it
  • Ice
  • Iontophoresis
69
Q

PT Interventions - Caution

A

Temporomandibular techniques

  • Use caution - joint swells easily
  • More is not always better … sometimes its just more.
70
Q

PT Interventions - HEP

A
  • HEP
  • > Instruct patient to do exercises at home
  • Address cervical spine & upper quarter
71
Q

Intervention - Oral Appliances

A
  • Upper & lower appliances
  • Dentist fabricates & adjusts appliances
  • Used to address teeth
  • Physical therapist facilitates soft tissue adaptation
72
Q

Surgery

A
  • Performed by oral surgeon specializing in TMD
  • PT encourage early referral post-operatively
  • Arthrocentesis
  • Arthroscopy
  • Arthrotomy - open joint
  • Menisectomy and/or condylectomy
  • Temporomandibular implants
73
Q

Big Picture

A
  • Interdisciplinary teamwork

- >Dentists & physical therapists working together achieve the best functional outcomes for clients with TMD

Ortho 3 (4 decks)

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