TMD Flashcards
TMJ Anatomy
- only synovial joint in the cranium
- mandible condyle is bi-convex
- temporal bone portion is saddle shaped
- meniscus helps stabalize: translates anteriorly during depression of mandible; innervated at periphery; neural and avascular at force bearing zones
Digastric, suprahyoid
-depress mandible (infrahyoid stabalizes hyoid bone) initially, then pterygoids depress jaw
Left lateral and medial pterygoids
-move mandible lateral and forward to the right
Temporalis, masseter, medial pterygoid
-close jaw tightly
Buccinator
–approximates lips and compresses cheeks (blowing)
Depressor labii inferior
-protrudes lower lip (pouting)
Depressor anguli oris and platysma
-draw corner of mouth down
Mentalis
-draws tip of chin upward
Orbicularis oris
-approximates and compresses lips
Zygomatic minor
-protrudes upper lip
Levator anguli oris
-lifts upper border of lip on one side without raising lateral angle (snarl)
Zygomatic major
-raises lateral angle of mouth (smile)
Risorius
-approximates lips and draws tips and draws corners lateral (grimace)
Intracapsular TMJ pathology
-infection, RA, OA, gout, metastatic CA, articular disc displacements
Extracapsular TMJ pathology
- Myofascial pain of masticatory muscles
- TMJ myofascial pain syndrome, TMJ dysfunction syndrome, TMJ syndrome
- TMJD: temporomandibular muscle and joint disorder
TMJ trauma
- direct or by whiplash injury
- if direct blow with closed mouth, posterior capsule injury
TMJ malocclusions
-deviation from normal contact of maxiallary and mandibular teeth
TMJ malocclusions class1
-1st molars normal, problem elsewhere
TMJ malocclusions class 2a
- lower 1st molar posterior to upper
- mandibular retrusion (overbite)
TMJ maloccusions class 2b
-lower 1st molar posterior to upper to greater degree (larger overbite)
TMJ maloccusions class 3
lower 1st molar anterior to upper mandibular protrusion (underbite)
TMJ muscle strain
- oral habits (tobacco, gum, etc)
- postural/work related (singers, phone operators, musicians)
- sports (trauma, mouthguards)
TMJ musculoskeletal problems
- developmental abnormalities–condylar hypoplasia/agenesis
- somatic dysfunction–temporal bone dysfunction; compensatory changes (short leg syndrome, scoliosis, etc)
TMJ Mood disorders
-anxiety, depression, post-traumatic stress disorder, history of abuse
some studies show association between chronic TMD and above disorders
TMJ and RA
-more likely to develop TM pain
Unilateral TMJ problem symptoms
- cephalgia–misdiagnosed as migraines
- otalgia
- neck pain
- eye pain
- shoulder and back pain
Most common signs and symptoms of TMD
- pain, ear discomfort or dysfunction, headache, TMJ discomfort
- patient may complain of cephalgia, and mention jaw problems or not mention jaw problems
- may describe as a dull ache that is worse with chewing
- tinnitus
More TMD symptoms
- difficulty opening mouth
- click, crepitus=jaw click usually present with disc displacement, but by itself non-diagnostic
- lateral deviation of jaw
- spasm within facial muscles
- onset of symptoms may correspond with onset of stress
- neck pain–trauma, bad posture, and musculoskeletal tension nine cervical area
- eye pain–orbital/perioribital pain ofen described as unilateral, constant, and boring
- arm/back pain–shoulder pain that radiates down arm +/- tingling or numbness
- dizziness associated with ear pain and stuffiness or cervical muscle strain and tension
Jaw clenching
- often due to anxiety and psychosocial stress
- does not interfere with treatment in most cases, although a severely disturbed capacity for interpersonal relationships associated with poor prognosis
Types of TMJ dysfunction
- opening click
- closing click (reciprocal clicking)
- inability to fully open jaw (close locked)
- inability to close–if bilateral
- crepitus and grating
- fusion of the joint (ankylossis)
Causes of TMJ click
- almost always due to disc displacement–after disc thin/stretched
- adhesions
- uncoorditated muscle action of pterygoids
- tear or perforation of disc
- osteoarthritis–more likely to have crepitus
- occlusional imbalance–less likely
TMD history
- most often complains of facial pain, headache, ear symptoms, TMJ pain, or symptoms of jaw dysfunction
- ask about history of jaw trauma, sleep habits/position, symptoms of nightime bruxism (jaw sore or HA in AM)
- past/present use mouth orthotics
- ask about occupation/hobbies; personal habits: usual posture, nail biting, or frequent gum chewing; symptoms of depression or anxiety; any recent stressful event
- include usual ROS: fever/chills/weight loss/PMH etc
TMJ evaluation
- osteopathic exam (not just cranial bones)
- complete evaluation, being especially careful to note symmetry/asymmetry-C spine; leg lengths
- palpate joints for crepitans/clicks
- palpate muscles of mastication
- ROM
- not facial asymmetry
- observe for cavities; suspicious lesions in mouth; alignment of teeth
PE findings with compelling signs of TMD
- abnormal mandibular movements
- decreased ROM of TMJ–normal functional opening is 35-55 mm; functional opening in TMD usually
Disc displacement
- symptoms of TMJD: MRI showed displaced disc in 84% of patients
- no symptoms of TMJD: 33% had displaced disc
TMD differential diagnosis
- inflammatory disease: local infection, RA, giant cell arteritis
- dental problems: loss of posterior teeth support
- Lymphoproliferative disorders
- migraine related disorders–carotodynia
- Eagle’s syndrome (stylohyoid syndrome)–elongated styloid process
- Neurlagias: trigeminal, glossopharygeal
- parotid gland disorders
TMD treatment
- nonpharmacologic: pt education; self-care aimed at improving pain and function (change head posture, sleeping position, and aggravated parafunctional oral behaviors
- patients usually respond to these noninvasive conservative treatments
- find cause and treat
- eliminate jaw stress: bite plate appliance to decrease nocturnal bruxism/jaw clenching; dental care; decrease chewing
- correct structural imbalances
- heat for muscle spasms
- jaw exercises
- decrease stress
- TENS unit
- biofeedback, relaxation techniques, habit reversal
- work with dentist
- oral devices/occlusal splints
TMD medication
- muscle relaxants, TCAs–give at nighttime; continue 1 month until pain is gone
- NSAIDS/analgesics usually not adequate
- narcotics not indicated unless severe trauma
- intraarticular steroids (once)
- botulinum toxin injections
TMD surgical correction
- last resort!
- TMJ prosthetic–attaches to mandible and skull
- consider if inflammatory arthritis involving TMJ, recurrent fibrosis, bony
- ankylosis, trauma, developmental abnormality, or pathologic lesion
