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Advanced Orthopedics > TMD (Temporal Mandibular Dysfunction) > Flashcards

TMD (Temporal Mandibular Dysfunction) Flashcards

1
Q

Normal mouth opening

A
  • 40 to 50 millimeters
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2
Q

Normal mouth protrusion

A
  • 8 to 10 millimeters
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3
Q

Normal lateral excursion

A
  • 8 to 10 millimeters
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4
Q

Common signs and symptoms of TMD

A
  • Headaches, frontal, temporal & occipital (cervicogenic)
  • Facial pain: masseter, temporalis, TMJ region, neuralgia
  • Ear pain: often seen first by ENT
  • Pain reported with eating & opening of mouth
  • Abnormal movement patterns oof the mandible noted
  • Popping & clicking
  • Usually coexists with cervical pain & other upper quarter dysfunction
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5
Q

Epidemiology of TMD

A
  • Usually females
  • 20-50 years old
  • Hx of facial head and neck trauma
  • Hx oof asymptomatic click from childhood or teen years
  • Hx of orthodontics (malocclusion)
  • Poor dentition
  • Often ectomorphic & hypermobile (Beighton score)
  • Referred from DDS, ENT, PCP
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6
Q

What muscles help with opening/mandibular depression

A
  • Gravity assisted & digastrics (supra hyoid group)
  • Assist later opening by lateral pterygoid upper portion
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7
Q

What muscles help with closing

A
  • Masseter
  • Temporalis
  • Medial pterygoids
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8
Q

What muscles help with protrusion

A
  • Bilateral heads of the superior lateral pterygoids & assisted by medial pterygoids
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9
Q

What muscles help with retrusion

A
  • Posterior temporalis
  • Assisted by deep masseter
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10
Q

What muscles help with lateral trusion/deviation

A
  • Contralateral contraction of medial pterygoid & lateral pterygooid
  • Ipsilateral temporalis & masseter
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11
Q

Describe the osteology of the TMJ

A
  • Mandibular condyle articulates with temporal bone (mandibular fossa) via the disc.
  • The disc separated the joint into upper and lower joint compartments
  • Articular surfaces are fibrocartilage, not hyaline - fibrocartilage can repair and remodel
  • Biconcave disc- superior convex and inferior concave articulating with condyle
  • Articular eminence/tubercle anteriorly
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12
Q

Describe the disc and capsule

A
  • Disc attached to medial and lateral poles of condyle and posteriorly to superior lamina which is elastic and allows it to stretch
  • Retrodiscal tissue: Superior lamina attaches to tympanic plate; Inferior lamina not elastic and attaches to neck of condyle
  • B/w 2 lamina is loose connective tissue that is rich in vascular and neural supply-painful when compressed
  • Capsule attaches inferiorly to neck of mandibular condyle; laterally and medially to circumference of temporal fossa (above disc is loose and below is tight); very vascular and innervated
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13
Q

Describe the biomechanics of the TMJ

A
  • 2 joints in one that is divided by a disc
  • Superior joint is larger & each joint has its own synovium
  • Superior joint is formed by fossa & superior surface of disc (gliding or anterior translation)
  • Inferior joint is formed by condyle & inferior surface oof disc (this is where anterior rotation of condyle under disc occurs)
  • Superior lamina allows disc to translate forward along the fossa
  • Inferior lamina tethers disc and limits forward translation of condyle
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14
Q

Describe the biomechanics of mandibular depression

A
  • Opening: anterior rotation of condyle on lower disc surface (1st 25mm of opening)
  • Anterior translation of disc/condyle along the fossa surface (further 25mm)
  • Normal opening is 40-50mm
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15
Q

Describe the biomechanics of mandibular protrusion & retraction

A
  • All translation occurs in upper joint space
  • Coondyle & disc translate together
  • Retro discal tissue stretches
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16
Q

Describe the biomechanics of lateral deviation to the right

A
  • R condyle rotation & L condyle translation
  • Normal ROM is 8-10mm
  • 1:4 ratio of lateral deviation to depression
17
Q

Describe a C-Curve

A

-Capsular pattern of restriction
- Usually no click or pop
- Mandible deviates towards restricted side

18
Q

Describe a S-Curve

A
  • Anterior displacement of disc off condyle
  • Anterior translation is blocked until disc reduces itself on condyle during depression
  • After reduction of disc then mandible returns to midline
  • Usually associated with click or pop
19
Q

Describe deviations

A
  • Lateral movements with return to midline
  • The opening pathway is altered but returns to midline
  • Usually indicative of a disc displacement with reduction or could be neuromuscular dysfucntion
20
Q

Describe deflections

A
  • Lateral movements without return to midline
  • Deflections are usually associated with disc dislocations without reduction or a unilateral muscle restriction
21
Q

Describe the meaning of pops or clicks in the TMJ

A
  • Can be normal
  • Hx of parafunctional activity: Bruxism (grinding at night) common
  • Auscultation can be used but not necessary
  • Opening & closing clicks indicative of disc displacement with reduction
22
Q

What would you look for in a patient’s posture/observe for TMD

A
  • Sitting/standing posture
  • Posture rotation of cranium
  • Facial symmetry
  • Observe with tongue in resting position
  • Signs of parafunctional habits: masseter hypertrophy
23
Q

Describe the cervical relationship to TMJ involvement

A
  • Forward head posture (FHP) creates mandible depression, tension & fatigue of anterior supra hyoid muscles, tightening of posterior extensor mm
  • Thought to translate mandible superiorly & posteriorly forcing condyle up into fossa contributing to disc dislocation/cumulative tissue trauma
24
Q
A
24
Q

Normal TMJ ROM values

A
  • Opening: 40-50mm
  • Closing: look at mandible position = midline, cross bite, overbite, underbite
  • Lateral: 8-10mm
  • Protrusion: 10mm
  • Retrusion: 5mm
25
Q

Describe the TMJ compression bite test

A
  • Comprised of forceful unilateral biting for 20 sec on a tongue depressor in the first molar region
  • Familiar pain on the contralateral side to the clenching side is considered a positive test for joint pain & ipsilateral pain is indicative of muscle disorder
  • Contralateral = joint issue
  • Ipsilateral = muscle issue
  • A patient can have both
26
Q

Describe disc displacement with reduction

A
  • Opening & closing clicks (may have 2 clicks on closing)
  • Disc displacement without reduction is a progression of the former
  • 1st opening click
  • 2nd opening click
  • Locking
  • 1st closing click
  • 2nd closing click
27
Q

Describe a near screen for TMD

A
  • Test facial nerve & UE dermatomal scan
  • UE deep tendon reflexes
  • Test Trigeminal nerve
  • Motor testing of mandible, lateral deviation, clenching, & opening
28
Q

Describe disc displacement without reduction

A
  • Disc remains displaced anteriorly blocking anterior rotation & translation for full opening motion
  • Redistricts movement to ~25mm
  • No click as disc is stuck in anterior position
29
Q

Describe joint pain

A
  • Dull or sharp pain at the TMJ or inside ear associated with chewing on opposite side, sleeping on same side
30
Q

Describe muscle pain

A
  • Dull ache, anterior to TMJ, at temporal region, associated with same side chewing or clenching with stress
31
Q

List the functional outcome measures for TMD

A
  • TMJ disability index (TDI)
  • TMJ disability index questionnaire: Steigerwald/Maher
  • Patient specific functional scale
  • TSK-TMD (Tampa scale of Kinesiophobia-TMD) if chronic pain is a factor
32
Q

Describe the TMJ classifications

A
  • Group I Masticatroy muscle disorder: Ia = with normal opening; Ib = with limited opening
  • Group II Disc displacement: IIa = with reduction; IIb = without reduction with limited opening; IIc = without reduction without limited opening
  • Group III Joint dysfunction: IIIa = arthralgia; IIIb = osteoarthritis; IIIc = osteoarthrosis
33
Q

Describe primary HA Hx

A
  • Migraine
  • Tension type
  • Cluster
34
Q

Describe secondary HA

A
  • Medical Hx of HTN, cardiac HX, angina
  • Systemic: RA, lupus, fibromyalgia, bilateral pain
  • Cervical posture, DNF strength, ROM, posture, segmental motion, palpation
  • Dental: Hx, teeth, bite, observation of oral cavity
  • Ear: Hx, otoscope, pressure over tragus
  • SinusL sinus pain, nasal congestion, reduced smell, sinus tap test
  • Eye: acute vision loss, eye pin with eye movement, palpation temporal artery
  • Cranial neuralgia (CNS)
35
Q

Treatment interventions for TMD

A
  • Education: dietary (softer diet, switch sides when chewing, avoid foods that require big bites), reduce parafunctiional habits (bruxism, lip biting), functional habits (avoid WBing on joint, adapted yawning - block or tongue position), psychological factors, pain science education, & coping strategies
  • Modalities: Estim, iontophoresis, dry needling, ultrasound (up for discussion)
  • Therapeutic exercises: Rocabado 6x6 program & Kraus TMD exercises
36
Q

Describe Recabado 6x6 program

A
  • 6 exercises, 6 reps, 6x/day
37
Q

Describe Kraus TMD exercises

A
  • Includes inhibition of excessive masticatory muscle activity
  • Neuromuscular control
  • Choose interventions to address pain, joint clicking, muscle asymmetry, deviations in active ROM patterns & spasms that limit opening
38
Q

Lists the different joint mobilizations we can do for TMD

A
  • Distraction
  • Anterior glides
  • Unilateral caudal lateral glide (sitting)
  • Medial/lateral glide
  • Caudal anterior medial (CAM)
  • Self mobilization of TMJ for medial glide
  • Soft tissue mobilization: friction massage, trigger point release (intra/extra oral)

Advanced Orthopedics (29 decks)

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