TMD, facial muscles Flashcards
TMJ vs. TMD
TMJ: stomatognathic system
TMD: group of MSK disorders w/ signs and symptoms
True or false: TMD just involves TMJ joint?
False! muscles of mastication, c-spine etc are involved
Peak age of prevalence of TMD?
35-45
What two bones is the TMJ made of?
Process of the temporal bone and head of the condyle
What kind of joint is TMJ
Compound, complex (moves in three planes) synovial jt.
What muscle attaches on the coronoid process?
Temporalis
What is the articulating part of TMJ?
Articular tubercle and head of the condyle
What shape are the articulating surfaces of the TMJ?
Articular tubercle: convex
Head of condyle: convex
Convex on convex
What shape is the articular disc and what bearing does this have on its function?
Biconcave, thicker at the ends, thinner at the middle for stability due to surfaces being convex on convex
What parts of the articular disc are innervated?
Anterior and posterior
Describe the central portion of the articular disc. Why?
Aneural and avascular. This is where all the force goes, it would be really painful if this weren’t the case.
The TMJ is made of what?
fibrocartilage
What is fibrocartilage (what TMJ is made of) good at:
resisting shear and compressive forces
DDD in TMJ prognosis?
not bad! fibrocartilage repairs
Superior and inferior stratum are what and part of ________
Ligamentous structures. Bilaminar zone of the TMJ.
The articular disc breaks joint into what?What are the actions of these two parts?
superior and inferior joint space
Superior: restricts forward movement of disc during opening
Inferior: assists pulling disc posteriorly during closing
Describe the anterior attachment of the intra articular disc
Weakest part of the joint
The lateral pterygoid attaches here
Explain the retrodiscal tissue/pad
highly vascular and neural
Describe the capsular ligament
Lateral and medial attachment of the intra-articular disc to the TMJ
Covers the entire joint, retains synovial fluid, resists separation
What covers the entire TMJ, retains synovial fluid and resists separation?
Capsular ligament
Describe the discal ligaments
LDL, MDL named for being on the medial/lateral poles of the condyle
Which is thinner LDL or MDL?
LDL
Role of the temporomandibular ligament
tightens to give lateral stability when the mouth opens: controls rotation of the condyle, limits posterior movement of the condyle
Calcification of what ligament is called Eagles syndrome?
Stylomandibular
Trigeminal N is what CN?
5
name the three branches of CNV
Opthalamic
Maxillary
Mandibular
Sensory branch of CNV covers what?
the entire lateral portion of the face
What portion of the TMJ is highly innervated
Posterior and lateral - this is where the structures are which create the most pain.
What point of the TMJ is NOT well innervated
anterior and medial
What does the articular disk articulate with superiorly? Inferiorly?
Superiorly: articular eminence
Inferiorly: mandibular condyle
Describe mandibular motions
Depressing and elevating
Protrusion and retrusion
Lateral excursion
True muscles of mastication are innervated by what N
Trigeminal N.
Name the 4 muscles of mastication
Temporalis
Masseter (has superficial and deep)
Medial pterygoid
Lateral Pterygoid
Function of the supra and infrahyoid muscles
stabilize the hyoid bone allowing swallowing
Temporalis actions
Bilateral: _____
Unilateral: _____
Posterior fibers: ______
Bilateral: elevation/closing
Unilateral: mandibular deviation same side
Posterior fibers: retraction (bringing your tongue backwards on the roof of your mouth
Temporalis function
guides biting motion
Name the three muscles of mastication that elevate
Temporalis, masseter, medial pterygoid
Name the two muscles that work to depress/open the mandible
Bilateral inferior pterygoids
Digastric
Describe the location of the deep and superficial masseter in relation to one another
Superficial: anterior 2/3 of zygomatic arch. superior –> inferior with a little angle
Deep: posterior 1/3 of zygomatic arch, runs almost directly vertically
Both attach on the angle of the mandible
Describe the difference between superficial and deep masseter
Superficial: used with light clench
Deep: used for forceful clench
Medial Pterygoid runs which direction
superior to inferior and a little medial to lateral: mirrors the masseter muscle but internally
Actions of the medial pterygoid
Function: ____
Bilateral: _____
Unilateral: ______
Function: chewing
Bilateral: elevation/closing
Unilateral: lateral excursion to the opposite side of the muscle firing, PROTRUSION
Is the inferior or superior lateral pterygoid active in forceful mandibular closure?
Superior lateral pterygoid
3 actions of the inferior lateral pterygoid?
action of the superior lateral pterygoid?
bilateral: protrusion, mandibular depression
Unilateral: lateral excursion to the opposite side
Superior: active in forceful mandibular closure
Both lateral pterygoid muscles when working unilaterally cause what?
lateral movement to the contralateral side
Suprahyoid muscles run from where to where and what two actions
Runs from hyoid to mandible
Function: assist in mandibular depression and swallowing
Infrahyoid muscles run from where to where and what action
Run from hyoid bone to clavicle and sternum
Function: stabilize the hyoid bone to allow for swallowing
Digastric muscles are part of what group of muscles? Function?
Classification: Suprahyoid
Function: Mandibular depression/opening
Digastric and lateral pterygoid relationship for mandible depression
Digastric (anterior and posterior) moves first, then lateral pterygoids fire to help with the gliding motion which is the last part of the mechanics of opening your mouth
What two muscles are most involved in opening of the mouth
Anterior and posterior digastric –> lateral pterygoids
What is considered normal mandibular opening?
hypermobility?
Functional?
limited?
Anecdotally she has found how many mm has been huge for people
40-50mm = normal
> 50 = hyper
> 30: functional
<35: limited
Anecdotally: 20mm
Rolling/rotation occurs in inferior or superior joint space?
Inferior
Translation occurs in inferior or superior jt. space?
Superior
In the rotation part of mandibular opening what tightens to give lateral stability?
Temporomandibular ligament
Every time you open your mouth what gets stretched
retrodiscal tissue which holds the articular disc in place
Which direction does the disc and condyle move during translation
Anterior and inferior: happening in the superior jt. space
Mandibular opening:
Activation of _____ and _____
Mandibular condyle rotates and states to translate _____ disc rotates ____ on condyle
Whats happening in the superior ligamentous complex?
Activation of DIGASTRIC and INFERIOR LATERAL PTERYGOID
Mandibular condyle rotates and starts to translate ANTERIORLY, disc rotates POSTERIORLY
Tension develops in the superior stratum/ligamentous complex allowing translation forward while also controlling the amount of anterior translation with a posterior pull
Mandibular closing
Condyle rotates ______ disc rotates ______ on _____
Contraction of ________
What 3 other muscles are involved in elevation/closing?
Condyle rotates POSTEIRORLY, disc rotates ANTERIORLY on CONDYLE
Contraction of SUPERIOR LATERAL PTERYGOID
Other muscles involved in elevation/closing: temporalis, masseter, medial pterygoid
What is normal protrusion?
Funcitonal protrusion?
Normal: 6-7mm
Functional: end to end position of central incisors in front of upper teeth
Arthrokinematics of protraction? What is moving and in what way?
Bilateral condyle TRANSLATION (superior part of the joint space)
True or false: you can have deviations and deflections in protrusion movement?
True
Main muscle of protrusion? Which helps?
Bilateral inferior lateral pterygoid
Masseter helps a little
Two main muscle of retrusion?
Middle and posterior fibers of temporalis, suprahyoid muscles
What is normal lateral excursion?
Functional?
What counts as a significant difference?
8-12mm
Functional: end to end position of lower canine to upper canine
Significant difference 4-5mm difference
Arthorkinematics of lateral excursion?
Anterior translation on contralateral side
What two muscles are involved in the force couple causing spinning of condyle during lateral excursion?
IPSILATERAL
Posterior temporalis exerting a posterior force
Lateral pterygoid exerting an anterior force
If the jaw is doing lateral excursion to the R what muscles are actively causing this movement?
The LEFT lateral and medial pterygoids (they go medial to lateral)
Describe lateral excursion athrokinematics
Ipsilateral:
Contralateral:
Ipsilateral: force couple between posterior temporalis and lateral pterygoid causing condylar spin in place
Contralateral: medial and lateral pterygoid action causing condyle and disc to translate anteriorly
How did TMD used to be treated.
Malocclusion: teeth don’t fit together correctly
What kind of problem is TMD
MSK! not dental
When are radiographs a good idea for TMD
Red flags present
No response to conservative care
What kind of care is recommended for acute and chronic TMD?
conservative, reversible, cost-effective; chronic or acute!
What kind of imaging is the most sensitive for articular disc dysfunciton?
MRI
What kind of imaging would be used to look at a condylar fracture?
CT
Define
Odontalgia
Otalgia
Odontalgia: tooth pain
Otalgia: ear pain
Occlusion means? and what is the relevance of this
Teeth don’t fit together, we don’t treat this so we need to have them stop focusing on this if they are
extrememly painful, sharp, lancinating pain
Trigemninal neuralgia
tenderness over the temporal area, medical emergency, blindness is a fear
Temporal arteritis
atypical face or tooth pain
Atypical odontalgia
Post-shingles, want to inspect vesicles in the temporal area
Post herpetic neuralgia
Ticks in facial muscles
Orofacial movement disorder
What are some specific things you want to ask/ look at for exam of TMD pt
pain with mandibular activities
Jt sounds, locking etc
Dental hx
Associated symptoms: malocclusion, HA, dizzy, ear pain, etc.
Deviation vs. Deflection
Deviation: C
Deflection: S
Palpating:
Preauricular area
Intraauricular area
Preauricular: just anterior to tragus
Intraauricular: inside the ear with the pinky
TMJ joint provocation test
cotton role test
+ if pt feels pain on opposite side of cotton ball
Explain a cotton role test biomechanics
Pt bites down on cotton ball on one side, that pushes the condyle of the opposite side up into that sensitive retrodiscal tissue and possibly inflammed capsule.
How would you screen for facial N?
Raise eyebrows, close your eyes, big smile, pout your lip etc.
Common cause of TMJ joint pain
Synovitis, capsulitis
Common symptoms of synovitis or capsulitis
Pain on palpation right over jt., pain w/mandibular movement, altered mandibular ROM
Pain right in front of ear indicative of what?
arthralgia
Provocation of arthralgia
Medical diagnosis?
Palpation over lateral pole of joint, max ROM, + jt loading test
MRI: fluid in the jt.
Common tx for arthralgia
control mouth opening (yawning, eating etc), “no chew”, rest position, modalities, manual therapy, postural correction
What is the mandibular rest position
tongue up, teeth apart, lips together
Describe how to teach controlled opening
tongue up, as if you were going to say no, open mouth maintaining this
What is the click you may hear during mandibular motion (opening and closing as well as lateral excursion) with a disc displacement?
The articular disc being recaptured
If someones R disc is displaced anteriorly and they open their mouth? which way will the mandible deviate?
R disc is displaced anteriorly therefore the L will go faster pushing the jaw to the R
What ROM deficits does someone with a disc displacement generally present with?
none! often full ROM
Exam for DDwR criteria
+ for jt noise 1/3 reps during opening and closing, lateral excursion or protrusive movements
if there is a click w/opening and closing there should be noise elimination with “edge to edge” technique/protrusion
Tx for DDWR
pt education: decrease jt loading
Treat arthralgia, muscle, cspine pain as indicated: controlled opening, open and close w/o clicking
Modalities
Techniques to cause disc recapture
Edge to edge technique
Opening w/lateral tongue placement
Rocabado technique: use lateral excursion or protrusion to recapture the disk, disc is stabilized by gentle bite w/return to midline, isometrics used to stabilize it
What does someone with DDWoR present with?
maximum opening <30mm
Decreased protrusion
Decreased lateral excursion to the opposite side
R DDWo reduction. Lateral excursion would be limited what direction?
Limited to the L
R DDWo reduction. Jaw would deviate which direction with opening?
Deviation to the R
Tx for DDWoR
Modalities: arthralgia and muscle pain
- estim w/ dynamic stretch
- US w/ passive stretch
Jt mobilizations: for hypomobile, pain control
W/O limited opening: pt education
If a disc is acutely displaced what two exercises can you do?
Tongue up in midline
Tongue up and away from involved side/deviation in opening
What happens with a condylar jump?
condyle goes past the articular eminence
What would a L subluxation look like?
Sudden movement to the contralateral side
What occurs when someone is in an “open lock”
Dislocation: condyle and disk are caught anteriorly
Dx of subluxation/dislocation
unable to return to normal position w/o self manuever
May have clicking at end of opening or beginning of closing
Possible jutter or sudden change in condylar direction
Tx subgroups for hypermobility including subluxation
Pt education: parafunction and diet modification
Exercise: mandibular control, stabilization, cervical and scapular strengthening
Specific exercises for subluxation or hypermobile
Controlled active motion, isometrics, resisted opening, controlled excursion (just a little controlled motion side to side)
What is a TMJ jt disease?
DJD/OA: talking about the fibrocartilage and the jt itself
How do we know if someone has DJD and we’re not looking at imaging?
Crepitus w/ palpation
Tx for DMD
If painful treat the pain, modalities, postural exercise, controlled opening
Masseter referred pain
Muscle belly
Insertion
Deep
muscle belly: posterior teeth of maxillary and mandibular, mandible and maxilla
Insertion: mandible and supraorbital area
Deep: deep ear
Lateral Pterygoid Referred pain
maxillary area, in front of ear
Medial Pterygoid Referred pain
just in front of the ear
Temporalis referred pain
refers to top teeth, even to the front, temporal area
Confirming myalgia dx?
repeated chief complaint of pain with palpation, or with opening movements
Education points for myalgia
awareness of habits, posture and patterns of jaw use
- mandibular resting position: tongue up, teeth apart, lips together
Different tx for myalgia than other TMD disorders?
scapular strengthening
NMES to fatigue the muscle
Intra-oral soft tissue massage
What do you need to be congizant of when treating TMD?
C-SPine!
SCM referral pattern
supraorbital pain and face
What is a major source of HA facial and jaw pain?
Cervical zgapophyseal joints, trigger point referral
Splenius referral
banded portion of the head
Trapezius referral
temporal area, wrapping around skull to area of upper trap attachment, a little mandible
Examination of the C-spine
Flexion rotation test
Spurlings
Craniocervical flexion (deep neck flexors)
PA and side glides
Explain the Trigeminal cervical nucleus
Info from CN5 (trigminal) goes into the brainstem into the nucleus. Info from C1,2,3 also goes into the SC. As they both enter the dorsal column of the SC they overlap, the two then travel together to the brain confusing the signal through convergence
Ex: for cspine and TMD
flexor and extensor endurance
stabilization through isometrics
Scapular strengthening
Mandibular rest position, controlled mandibular rotation, rhythmic stabilization (isometrics of the jaw), cervical joint liberation, axial extension, shoulder girdle retraction are all?
Rocobado 6x6
MIO
Objective measure: maximal interincical opening
Modified SSI
Modified symptom severity index: pt centered outcome
Splint therapy generally used for what?
protect teeth from clenching
Whats not good about an NTI
it offloads your back teeth but that means all the force is on the front teeth which could cause the back teeth to grow and then you ave an anterior open bite
Posterior open bite causes
shift of teeth or tight muscles
Arthrocentesis
injection of fluid into the joint
Arthroscopy
lavage and lysis of adhesion, steriod injection
Common reasons Arthroplasy of TMJ?
Trauma, RA
Orthognathic
Moving jaw forward or backwards surgically
Does diplopia resolve when one eye is covered?
If yes its binocular
What are the three main causes of binocular diplopia
eye muscle dysfunction
CN dysfunction
BS or intracranial process
Tension in the superior stratum allows what?
mandibular opening
what TMD disorder can be confirmed wth a CT scan?
condylar fracture
DDD: you’ll see narrowing of the joint space
