TMJ Flashcards
How many times is TMJ used daily
1500-2000 times
Who is TMJ 3-5x more prevalent in
Women around reproductive age
What is Occulsion
Functional relationship between maxillary and mandibular teeth
What is Bruxism
Grinding
What is clenching
Overacted masseter and temporalis resulting in increased compressive force between teeth
What is the free way space
Space between occluding surfaces of teeth when the mandible is in resting positions
2-4 mm normla
What is considered an over bite
The mandibular center incisor that is covered by the maxillary center incisor when the mandible is in the maximally occluded position
What is normal range for over bite
1/3 of the mandibular center incisor
What is over jet
Horizontal distance between the maxillary arch and the mandibular arch when the mandible is in its maximally occluded position
What is the normal range for overjet
3-6mm
What is underbite
Mandibular teeth sit further anterior than maximllary teeth
What is cross bite
Occlusal irregularity where the mandibular teeth and maxillary teeth are not in line with the center incisors
What is open bite
Full occlusion , molars are in approximation but front teeth dont touch
What kind of joint is the TMJ
Diarthrodial
- synovial joint with fibrocartilaginous surfaces and articular disc
What is the TMJ disc covered with and how should it move
Fibrocartilage
Bicconcave and should move with the mandibular condyle throughout jaw movement
Where does the disc attach for TMJ anteriorly and posteriorly
Anteriorly to the joint capsule and the superior lateral pterygoid
Posteriorly to the retrodiscal tissue
What are the 3 divisions of teh disc and are they vascular
V 1. Anterior: vascular and neural
2. Intermediate: avascular and aneural
3. Posterior: vascular and neural
What happens at the inferior cavity and superior cavity of the disc for TMJ
The inferior cavity—this is where rotation of the condyle occurs
* The superior cavity—this is where translation of the condyle occurs
Retrodiscal tissue is ____ and ____
vascular and nociceptive
Where is the capsule thicker
Medial and lateral
What TMJ function is lateral pterygoid invovled in
Elevation
Depression
Protrusion
Lateral excursion
EVERYTHING BUT RETRUSION
What mm are invovled in retrusion
Deep fibers of masseter, temporalis,
suprahyoids (digastric)
What mm are invovled in depression
Inferior fibers of lateral pterygoid,
suprahyoids, infrahyoids (indirectly)
What mm are invled in elevation
Masseter, temporalis, medial
pterygoid, superior fibers of lateral
pterygoid (stabilize the disk)
LTMM-like too much mastication
What mms are invovled in lateral excursion
Ipsilateral temporalis and masseter,
contralateral medial and lateral
pterygoid
What is the suprahyoids responsible for
Depression and retrusion of the mandible during mouth opening
What mm Work to stabilize the hyoid bone to form a firm base for the action
of the suprahyoid
Infrahyoid
What mm helps guide the disc and is very important
Lateral pterygoids
What is the only contractile tissue that attaches directly to the disc
Lateral pterygoids
Which mm will usually be tight and which mm will usually be weak or inhibited
Mm that close = tight
Mm that open = weak and inhibited
What is the nerve and blood vessel invovled with the TMJ
Mandibular branch n of trigeminal n ( CN V3)
Superficial temporal artery and maxillary artery
How is the resting position for the TMJ
Disc should sit slightly anterior to the condyle
Convex on concave
When the TMJ is opening what occurs in the first 20-25 mm of motin
Rotation
When does translation of TMJ opening occur, what way does the condyle and anterior mandible move
Later phase
Condyle move anterior and inferiorly
Anterior mandible move posterior and inferiorly
What happens during TMJ closing at the condyles and anterior mandible
- The condyles move posteriorly and superiorly
- The anterior mandible moves anteriorly and superiorly
What happens at the condyles during lateral deviation (rotation and translation)
Unilateral rotation of IPSILATRAL condyle
Unilateral horizontal translation of CONTRA condyle
How does the mandible move during protrusion/retrusion
Mandible slides slightly downward during protrusion and slightly upward during retrusion
How is the condyle and disc during protrusion and retrusion
Follows teh down ward slope of the articular eminence
What is the normal opening of teh TMJ??? Men ? Women ? What is considered functional
40-60mm
- 40-45 in males
- 45-50 in females
- 35 mm is considered functional
What is the normal opening for lateral deviation
1/4 opening
~10mm is normal
What is the normal motion for protrusion and retrusion
5-10 mm protrusion
3mm retrusion
During quick measurement how many fingers should opening be and what is functional
4 fingers of dominant hand
Functional is 3 fingers
What are the parafucntional habits that lend to misuse overuse of TMJ
• Clenching/grinding of teeth (Over-activation of
masticatory muscles)
• Gum chewing
• Other oral fixation
What psychosocial things can lead to parafucntional habits of TMJ
Anxiety and depression
TMK has high prevalence in chronic pain population especially ___
Fibromyalgia
Anterior disc displacement w reduction: pathoantomy
Disc lies anterior to the condyle at rest
**Anterior Disc Displacement with
Reduction **(ADDwR): what happens during opening
condyles reduce over the posterior
region, which can cause an opening click, and then
normal function resumes.
Anterior Disc Displacement with
Reduction (ADDwR): what happens during closing
the disc and condyle translate together
posteriorly. At the end of the closing range, the disc displaces anteriorly again due to the excessive contraction of the lateral pterygoid. This can cause a second click, called a closing click
When are the clicks for anterior disc displacement w reduction
can have opening click, closing click, both
(reciprocal clicks) or none at all
Why would someone have anterior disc displacement w reduction
Bc teh superior lateral pterygoids and superior retrodiscal lamina act as a guide wires in positioning of the disc so if there is an issue w this guide wire the disc position can be compromised
or/and
If there are morphological issues with either the collateral ligament or retrodiscal tissue , this can affect the interarticularis disc pressure
Can we change soemthing if it is morphological
Nahhhh but our manual treatments can address proper disc position
What is the pathoantaotmy for anterior disc displacement w/o reduction
Elasticity is lost in the ligament and retrodiscal tissue , keeping the condyles from being able to glide over the disc
If there is limited opening for ADDwoR then what is happening
Disc is blocking the condylar head
If there is no limitation in opening for the ADDwoR then what is happening
Disc is completely displaced anteriorly
Is there clicking with ADDwoR
NOOOOO NOOO NOOO
What are some Masticatory Muscle Disorder (7)
• Myofascial pain disorder
syndrome
• Trismus (muscular lock jaw)
• Myositis
• Myospasm
• Dystonia
• Myofibrotic contracture
• Neoplasm
What are joint dysfunctions in the TMJ
• OA
• RA
• Psoriatic arthritis
• Capsulitis
• synovitis
• Headaches
• Ear issues
• Vertigo/dizziness
• Swallowing/speech
disorders
• Psychological affect
• Trigeminal Neuralgia
• Temporal Arteritis • Post Herpectic Neuralgia
• Meniere’s disease
• Cervical/postural
contributions
• Chronic pain, fibromyalgia
What are these things
Associated conditions to TMJ
What shoudl we make sure we rule out when doing TMJ
Hx of neck pain and HA bc they are highly correlated
What are some things you shoudl ask during hx of TMJ
- eating
- dental work (night gaurd, retainer)
- popping or clicking
- jaw getting stuck
- ringing in ears
- changes in voice
- recent stressful situation
During the seated examination with no gloves what are u looking for
Open/close motin analysis
Listening for crepitus upon closing and opening
Cotton roll test
Jaw jerk reflex
CN screen
C spine scree , T spine screech , UQ screen
Posture
Joint assessment of 1st ribs
What is the C shape opening asymmetry ?
S shaped opening asymmetry ?
Deflection?
C-shaped opening=capsular pattern (C deviates to the side of
restriction)
- S-shaped opening=lack of motor control
- Deflection=anterior disc displacement (typically towards side of
displaced disc)
What is the cotton roll test
Bite object on painful side molars
If pain increased = muscular origin
If pain decreased= joint related
If confir joint test the non painful side and if it is joint then it should still result in pain
What should ur supine examination - no gloves include
-mm palpation (masseter , temporalis)
- joint asssesment ( C spine)
- mm strength testing (deep neck flexors)
- mm length test (pec minor , major , lats)
- mandibular neurodynamic testing
Why do u test mandibular neurodynamic testing
U suspect neural origin of pain
How do u test mandibular neurodynamic testing
Patient lie supine , arms by side and hands on abs
Patient head is positioned over end of table and rests against PT abs
PT support the patient head w both hands at the occipital area and places both thumbs on the manibdualr angles
PT put patient into capital c flexion then laterally flexors teh upper C spine contralaterally
Both cervical movements are performed as fat as possible to load the intracranial structures , but without provoking nay pain
Then a lateral glide movements of the mandible towards ther contralateral side
How do u check for structural differentiation after doing the mandibular neurodynamic testing
Do it with c spine in neutral
What mm are u palatine in supine with gloves
Medial pterygoid and lateral
How do u palpation the medial pterygoid
Slide finger loan mandibular teeth until u feel a rope like bundle just posterior to the back molar
What exam would u do if u Identify discal issues
Centric relation provocation test
How do u perform the centric relation provocation test (for discal issues)
Grasp lower mandible with index and ring finger externally gripping angle of mandible and the thumb on the top of the mandibular teeth
Keep jaw slightly open while scooping the aw into the joint space (push anterior- superior
What is the (+) test for centric relation provaction test
if pain recreated anterior to tragus, indicating
structural pathology of the disc complex
If you really think its disc, test this last! (think of it
like meniscal testing
What is the general treatment formula for TMJ
- address motion deficits
- neuromuscular redaction (retrain lateral pterygoid)
-eliminate self destructive habits
- pertinent ADL modicaiotns
- co mange w dentist if needed
What MET is used to increase opening
Resist closing , place thumb on bottom teeth
Is there usually a closing problem
No
What is the TUTALC education
• Tongue up on the roof of the mouth
• Teeth apart
• Lips closed
Perform at all times when not chewing , talking or exercising
How do u do a ADDwR exercise
- Instruct pt to open mouth maximally with the
opening click and then close mouth along a
protruded path - Contact teeth at the protruded position as the disc
is thought to be on top of the condyle - Then instruct the patient to carefully retrude the
condyle to the position just before the closing
click occurs - Open the mouth maximally again without an
opening click
Should u fix posture w TMJ probmelms
Yes
What modalities is potentially effective at the TMJ due to the superficiality of the joint and associated muscles
Ultrasound
Why are Suprahyoid Facilitation Exercises good
Easy to add in and help for coordinated movements
What are some Suprahyoid Facilitation Exercises
-Tongue clucking
-“N’s” = make N sound while depressing the jaw , 6-8 sends , 6-8 reps , -6-8 times a day
- tongue rolls
What is condyle emodeling exercise for
Used with ADDwR to get disc positioned correctly
How do u do the condylar remodeling exercise
Us tubing between teeth and have pt deviate laterally to contralateral side of symptomatic joint
