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Unit 13 > TMD, facial muscles > Flashcards

TMD, facial muscles Flashcards

1
Q

TMJ vs. TMD

A

TMJ: stomatognathic system

TMD: group of MSK disorders w/ signs and symptoms

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2
Q

True or false: TMD just involves TMJ joint?

A

False! muscles of mastication, c-spine etc are involved

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3
Q

Peak age of prevalence of TMD?

A

35-45

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4
Q

What two bones is the TMJ made of?

A

Process of the temporal bone and head of the condyle

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5
Q

What kind of joint is TMJ

A

Compound, complex (moves in three planes) synovial jt.

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6
Q

What muscle attaches on the coronoid process?

A

Temporalis

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7
Q

What is the articulating part of TMJ?

A

Articular tubercle and head of the condyle

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8
Q

What shape are the articulating surfaces of the TMJ?

A

Articular tubercle: convex

Head of condyle: convex

Convex on convex

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9
Q

What shape is the articular disc and what bearing does this have on its function?

A

Biconcave, thicker at the ends, thinner at the middle for stability due to surfaces being convex on convex

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10
Q

What parts of the articular disc are innervated?

A

Anterior and posterior

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11
Q

Describe the central portion of the articular disc. Why?

A

Aneural and avascular. This is where all the force goes, it would be really painful if this weren’t the case.

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12
Q

The TMJ is made of what?

A

fibrocartilage

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13
Q

What is fibrocartilage (what TMJ is made of) good at:

A

resisting shear and compressive forces

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14
Q

DDD in TMJ prognosis?

A

not bad! fibrocartilage repairs

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15
Q

Superior and inferior stratum are what and part of ________

A

Ligamentous structures. Bilaminar zone of the TMJ.

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16
Q

The articular disc breaks joint into what?What are the actions of these two parts?

A

superior and inferior joint space

Superior: restricts forward movement of disc during opening

Inferior: assists pulling disc posteriorly during closing

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17
Q

Describe the anterior attachment of the intra articular disc

A

Weakest part of the joint

The lateral pterygoid attaches here

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18
Q

Explain the retrodiscal tissue/pad

A

highly vascular and neural

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19
Q

Describe the capsular ligament

A

Lateral and medial attachment of the intra-articular disc to the TMJ

Covers the entire joint, retains synovial fluid, resists separation

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20
Q

What covers the entire TMJ, retains synovial fluid and resists separation?

A

Capsular ligament

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21
Q

Describe the discal ligaments

A

LDL, MDL named for being on the medial/lateral poles of the condyle

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22
Q

Which is thinner LDL or MDL?

A

LDL

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23
Q

Role of the temporomandibular ligament

A

tightens to give lateral stability when the mouth opens: controls rotation of the condyle, limits posterior movement of the condyle

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24
Q

Calcification of what ligament is called Eagles syndrome?

A

Stylomandibular

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25
Q

Trigeminal N is what CN?

A

5

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26
Q

name the three branches of CNV

A

Opthalamic
Maxillary
Mandibular

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27
Q

Sensory branch of CNV covers what?

A

the entire lateral portion of the face

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28
Q

What portion of the TMJ is highly innervated

A

Posterior and lateral - this is where the structures are which create the most pain.

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29
Q

What point of the TMJ is NOT well innervated

A

anterior and medial

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30
Q

What does the articular disk articulate with superiorly? Inferiorly?

A

Superiorly: articular eminence

Inferiorly: mandibular condyle

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31
Q

Describe mandibular motions

A

Depressing and elevating

Protrusion and retrusion

Lateral excursion

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32
Q

True muscles of mastication are innervated by what N

A

Trigeminal N.

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33
Q

Name the 4 muscles of mastication

A

Temporalis

Masseter (has superficial and deep)

Medial pterygoid

Lateral Pterygoid

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34
Q

Function of the supra and infrahyoid muscles

A

stabilize the hyoid bone allowing swallowing

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35
Q

Temporalis actions
Bilateral: _____
Unilateral: _____

Posterior fibers: ______

A

Bilateral: elevation/closing

Unilateral: mandibular deviation same side

Posterior fibers: retraction (bringing your tongue backwards on the roof of your mouth

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36
Q

Temporalis function

A

guides biting motion

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37
Q

Name the three muscles of mastication that elevate

A

Temporalis, masseter, medial pterygoid

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38
Q

Name the two muscles that work to depress/open the mandible

A

Bilateral inferior pterygoids

Digastric

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39
Q

Describe the location of the deep and superficial masseter in relation to one another

A

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

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40
Q

Describe the difference between superficial and deep masseter

A

Superficial: used with light clench

Deep: used for forceful clench

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41
Q

Medial Pterygoid runs which direction

A

superior to inferior and a little medial to lateral: mirrors the masseter muscle but internally

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42
Q

Actions of the medial pterygoid

Function: ____

Bilateral: _____
Unilateral: ______

A

Function: chewing

Bilateral: elevation/closing

Unilateral: lateral excursion to the opposite side of the muscle firing, PROTRUSION

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43
Q

Is the inferior or superior lateral pterygoid active in forceful mandibular closure?

A

Superior lateral pterygoid

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44
Q

3 actions of the inferior lateral pterygoid?

action of the superior lateral pterygoid?

A

bilateral: protrusion, mandibular depression
Unilateral: lateral excursion to the opposite side

Superior: active in forceful mandibular closure

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45
Q

Both lateral pterygoid muscles when working unilaterally cause what?

A

lateral movement to the contralateral side

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46
Q

Suprahyoid muscles run from where to where and what two actions

A

Runs from hyoid to mandible

Function: assist in mandibular depression and swallowing

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47
Q

Infrahyoid muscles run from where to where and what action

A

Run from hyoid bone to clavicle and sternum

Function: stabilize the hyoid bone to allow for swallowing

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48
Q

Digastric muscles are part of what group of muscles? Function?

A

Classification: Suprahyoid

Function: Mandibular depression/opening

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49
Q

Digastric and lateral pterygoid relationship for mandible depression

A

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

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50
Q

What two muscles are most involved in opening of the mouth

A

Anterior and posterior digastric –> lateral pterygoids

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51
Q

What is considered normal mandibular opening?

hypermobility?

Functional?

limited?

Anecdotally she has found how many mm has been huge for people

A

40-50mm = normal

> 50 = hyper

> 30: functional

<35: limited

Anecdotally: 20mm

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52
Q

Rolling/rotation occurs in inferior or superior joint space?

A

Inferior

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53
Q

Translation occurs in inferior or superior jt. space?

A

Superior

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54
Q

In the rotation part of mandibular opening what tightens to give lateral stability?

A

Temporomandibular ligament

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55
Q

Every time you open your mouth what gets stretched

A

retrodiscal tissue which holds the articular disc in place

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56
Q

Which direction does the disc and condyle move during translation

A

Anterior and inferior: happening in the superior jt. space

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57
Q

Mandibular opening:

Activation of _____ and _____

Mandibular condyle rotates and states to translate _____ disc rotates ____ on condyle

Whats happening in the superior ligamentous complex?

A

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

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58
Q

Mandibular closing

Condyle rotates ______ disc rotates ______ on _____

Contraction of ________

What 3 other muscles are involved in elevation/closing?

A

Condyle rotates POSTEIRORLY, disc rotates ANTERIORLY on CONDYLE

Contraction of SUPERIOR LATERAL PTERYGOID

Other muscles involved in elevation/closing: temporalis, masseter, medial pterygoid

59
Q

What is normal protrusion?

Funcitonal protrusion?

A

Normal: 6-7mm

Functional: end to end position of central incisors in front of upper teeth

60
Q

Arthrokinematics of protraction? What is moving and in what way?

A

Bilateral condyle TRANSLATION (superior part of the joint space)

61
Q

True or false: you can have deviations and deflections in protrusion movement?

A

True

62
Q

Main muscle of protrusion? Which helps?

A

Bilateral inferior lateral pterygoid

Masseter helps a little

63
Q

Two main muscle of retrusion?

A

Middle and posterior fibers of temporalis, suprahyoid muscles

64
Q

What is normal lateral excursion?

Functional?

What counts as a significant difference?

A

8-12mm

Functional: end to end position of lower canine to upper canine

Significant difference 4-5mm difference

65
Q

Arthorkinematics of lateral excursion?

A

Anterior translation on contralateral side

66
Q

What two muscles are involved in the force couple causing spinning of condyle during lateral excursion?

A

IPSILATERAL
Posterior temporalis exerting a posterior force

Lateral pterygoid exerting an anterior force

67
Q

If the jaw is doing lateral excursion to the R what muscles are actively causing this movement?

A

The LEFT lateral and medial pterygoids (they go medial to lateral)

68
Q

Describe lateral excursion athrokinematics

Ipsilateral:
Contralateral:

A

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

69
Q

How did TMD used to be treated.

A

Malocclusion: teeth don’t fit together correctly

70
Q

What kind of problem is TMD

A

MSK! not dental

71
Q

When are radiographs a good idea for TMD

A

Red flags present

No response to conservative care

72
Q

What kind of care is recommended for acute and chronic TMD?

A

conservative, reversible, cost-effective; chronic or acute!

73
Q

What kind of imaging is the most sensitive for articular disc dysfunciton?

A

MRI

74
Q

What kind of imaging would be used to look at a condylar fracture?

A

CT

75
Q

Define
Odontalgia
Otalgia

A

Odontalgia: tooth pain
Otalgia: ear pain

76
Q

Occlusion means? and what is the relevance of this

A

Teeth don’t fit together, we don’t treat this so we need to have them stop focusing on this if they are

77
Q

extrememly painful, sharp, lancinating pain

A

Trigemninal neuralgia

78
Q

tenderness over the temporal area, medical emergency, blindness is a fear

A

Temporal arteritis

79
Q

atypical face or tooth pain

A

Atypical odontalgia

80
Q

Post-shingles, want to inspect vesicles in the temporal area

A

Post herpetic neuralgia

81
Q

Ticks in facial muscles

A

Orofacial movement disorder

82
Q

What are some specific things you want to ask/ look at for exam of TMD pt

A

pain with mandibular activities

Jt sounds, locking etc

Dental hx

Associated symptoms: malocclusion, HA, dizzy, ear pain, etc.

83
Q

Deviation vs. Deflection

A

Deviation: C
Deflection: S

84
Q

Palpating:
Preauricular area

Intraauricular area

A

Preauricular: just anterior to tragus

Intraauricular: inside the ear with the pinky

85
Q

TMJ joint provocation test

A

cotton role test

+ if pt feels pain on opposite side of cotton ball

86
Q

Explain a cotton role test biomechanics

A

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.

87
Q

How would you screen for facial N?

A

Raise eyebrows, close your eyes, big smile, pout your lip etc.

88
Q

Common cause of TMJ joint pain

A

Synovitis, capsulitis

89
Q

Common symptoms of synovitis or capsulitis

A

Pain on palpation right over jt., pain w/mandibular movement, altered mandibular ROM

90
Q

Pain right in front of ear indicative of what?

A

arthralgia

91
Q

Provocation of arthralgia

Medical diagnosis?

A

Palpation over lateral pole of joint, max ROM, + jt loading test

MRI: fluid in the jt.

92
Q

Common tx for arthralgia

A

control mouth opening (yawning, eating etc), “no chew”, rest position, modalities, manual therapy, postural correction

93
Q

What is the mandibular rest position

A

tongue up, teeth apart, lips together

94
Q

Describe how to teach controlled opening

A

tongue up, as if you were going to say no, open mouth maintaining this

95
Q

What is the click you may hear during mandibular motion (opening and closing as well as lateral excursion) with a disc displacement?

A

The articular disc being recaptured

96
Q

If someones R disc is displaced anteriorly and they open their mouth? which way will the mandible deviate?

A

R disc is displaced anteriorly therefore the L will go faster pushing the jaw to the R

97
Q

What ROM deficits does someone with a disc displacement generally present with?

A

none! often full ROM

98
Q

Exam for DDwR criteria

A

+ 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

99
Q

Tx for DDWR

A

pt education: decrease jt loading

Treat arthralgia, muscle, cspine pain as indicated: controlled opening, open and close w/o clicking

Modalities

100
Q

Techniques to cause disc recapture

A

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

101
Q

What does someone with DDWoR present with?

A

maximum opening <30mm

Decreased protrusion

Decreased lateral excursion to the opposite side

102
Q

R DDWo reduction. Lateral excursion would be limited what direction?

A

Limited to the L

103
Q

R DDWo reduction. Jaw would deviate which direction with opening?

A

Deviation to the R

104
Q

Tx for DDWoR

A

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

105
Q

If a disc is acutely displaced what two exercises can you do?

A

Tongue up in midline

Tongue up and away from involved side/deviation in opening

106
Q

What happens with a condylar jump?

A

condyle goes past the articular eminence

107
Q

What would a L subluxation look like?

A

Sudden movement to the contralateral side

108
Q

What occurs when someone is in an “open lock”

A

Dislocation: condyle and disk are caught anteriorly

109
Q

Dx of subluxation/dislocation

A

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

110
Q

Tx subgroups for hypermobility including subluxation

A

Pt education: parafunction and diet modification

Exercise: mandibular control, stabilization, cervical and scapular strengthening

111
Q

Specific exercises for subluxation or hypermobile

A

Controlled active motion, isometrics, resisted opening, controlled excursion (just a little controlled motion side to side)

112
Q

What is a TMJ jt disease?

A

DJD/OA: talking about the fibrocartilage and the jt itself

113
Q

How do we know if someone has DJD and we’re not looking at imaging?

A

Crepitus w/ palpation

114
Q

Tx for DMD

A

If painful treat the pain, modalities, postural exercise, controlled opening

115
Q

Masseter referred pain
Muscle belly
Insertion
Deep

A

muscle belly: posterior teeth of maxillary and mandibular, mandible and maxilla

Insertion: mandible and supraorbital area

Deep: deep ear

116
Q

Lateral Pterygoid Referred pain

A

maxillary area, in front of ear

117
Q

Medial Pterygoid Referred pain

A

just in front of the ear

118
Q

Temporalis referred pain

A

refers to top teeth, even to the front, temporal area

119
Q

Confirming myalgia dx?

A

repeated chief complaint of pain with palpation, or with opening movements

120
Q

Education points for myalgia

A

awareness of habits, posture and patterns of jaw use

- mandibular resting position: tongue up, teeth apart, lips together

121
Q

Different tx for myalgia than other TMD disorders?

A

scapular strengthening

NMES to fatigue the muscle

Intra-oral soft tissue massage

122
Q

What do you need to be congizant of when treating TMD?

A

C-SPine!

123
Q

SCM referral pattern

A

supraorbital pain and face

124
Q

What is a major source of HA facial and jaw pain?

A

Cervical zgapophyseal joints, trigger point referral

125
Q

Splenius referral

A

banded portion of the head

126
Q

Trapezius referral

A

temporal area, wrapping around skull to area of upper trap attachment, a little mandible

127
Q

Examination of the C-spine

A

Flexion rotation test
Spurlings
Craniocervical flexion (deep neck flexors)
PA and side glides

128
Q

Explain the Trigeminal cervical nucleus

A

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

129
Q

Ex: for cspine and TMD

A

flexor and extensor endurance

stabilization through isometrics

Scapular strengthening

130
Q

Mandibular rest position, controlled mandibular rotation, rhythmic stabilization (isometrics of the jaw), cervical joint liberation, axial extension, shoulder girdle retraction are all?

A

Rocobado 6x6

131
Q

MIO

A

Objective measure: maximal interincical opening

132
Q

Modified SSI

A

Modified symptom severity index: pt centered outcome

133
Q

Splint therapy generally used for what?

A

protect teeth from clenching

134
Q

Whats not good about an NTI

A

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

135
Q

Posterior open bite causes

A

shift of teeth or tight muscles

136
Q

Arthrocentesis

A

injection of fluid into the joint

137
Q

Arthroscopy

A

lavage and lysis of adhesion, steriod injection

138
Q

Common reasons Arthroplasy of TMJ?

A

Trauma, RA

139
Q

Orthognathic

A

Moving jaw forward or backwards surgically

140
Q

Does diplopia resolve when one eye is covered?

A

If yes its binocular

141
Q

What are the three main causes of binocular diplopia

A

eye muscle dysfunction

CN dysfunction

BS or intracranial process

142
Q

Tension in the superior stratum allows what?

A

mandibular opening

143
Q

what TMD disorder can be confirmed wth a CT scan?

A

condylar fracture

DDD: you’ll see narrowing of the joint space

Unit 13 (6 decks)

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