TMD (Temporal Mandibular Dysfunction) Flashcards
1
Q
Normal mouth opening
A
- 40 to 50 millimeters
2
Q
Normal mouth protrusion
A
- 8 to 10 millimeters
3
Q
Normal lateral excursion
A
- 8 to 10 millimeters
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
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
6
Q
What muscles help with opening/mandibular depression
A
- Gravity assisted & digastrics (supra hyoid group)
- Assist later opening by lateral pterygoid upper portion
7
Q
What muscles help with closing
A
- Masseter
- Temporalis
- Medial pterygoids
8
Q
What muscles help with protrusion
A
- Bilateral heads of the superior lateral pterygoids & assisted by medial pterygoids
9
Q
What muscles help with retrusion
A
- Posterior temporalis
- Assisted by deep masseter
10
Q
What muscles help with lateral trusion/deviation
A
- Contralateral contraction of medial pterygoid & lateral pterygooid
- Ipsilateral temporalis & masseter
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
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
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
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
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
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)
