TMJ Flashcards
What are tempomandibular disorders characterized by?
1) Pain in pre auricular area, TMJ, or muscles of mastication
2) limitations/deviations in mandibular ROM
3) TMJ sounds during jaw function
What is the spectrum of symptoms for TMJ?
signs of symptoms: clicking, deviation, fatigue but no pain and no disability
OR
Severe pain with severe disability
What is onset of TMJ pain?
Acute: eating, impact jaw, dental procedures, yawning
Insidious onset repetitive trauma
What is tipping point for insidious onset?
Gradual progression of symptoms over time leading to pain
Clenching, bruxing, postural imbalance are forms of micro trauma
Have history of cervical whiplash injury (flex/ext type)
What is mechanism of TMJ pain?
Repetitive stress due to Restriction, compensation, and behaviors
1) restrictions: joint, soft tissue
2) Poorly controlled motion: muscle imbalance, poor quality of mvmt or sequencing, dental occlusion and loss/change in teeth
3) behaviors: posturing, grinding/clenching, fear avoidance behaviors/pain beliefs
What are the 5 potential pain generators?
1) Inflammation of ligaments/capsule: due to clenching/grinding from malocclusion
2) Internal derangement of ligament or disc: torn ligament that tethers the articular disc
3) Joint arthritis: result of disc tear and subsequent displacement overtime the joint surface breaks down
4) muscles: over pull or under pull leading to pain
5) Sensitization (central)
What is the disc in TMJ?
Dense fibrocartilage disc divides joint into a superior and inferior cavity filled with synovial fluid to lubricate joint
What happens in superior and inferior cavity of TMJ?
Superior: mandibular fossa and superior aspect of disc, translation occurs here
Inferior cavity: inferior aspect of disc and mandibular condyle, condyle rotation occurs here
What are 3 articular regions of the disc?
Anterior and posterior divisions have neural innervations and vascular supply
Intermediate portion is most dense, avascular, and aneural and gets nutrition from synovial fluid
What attaches to different portions of the disc?
Anterior: attaches to anterior capsule and superior head of lateral pterygoid
Medial and lateral: attaches to condylar head via the medial and lateral collateral ligaments
What are the ligaments of the TMJ?
Temporormandibular ligament (lateral ligament): limits posterior displacement during jaw opening
Collateral ligaments: resist excessive medial/lateral displacement of disc
Accessory ligaments: suspending mandible and preventing excessive protrusion
What is progression of joint noise?
Reciprocal clicks: loud click on opening is disc reduction, click on closing is disc dislocation
Once disc is fully displaced anteriorly and completely w/o reduction there will be no audible sound (leading to OA)
Single sound can be condyle touching disc or articular surface during opening or closing
What are stages of disc displacement?
Anterior disc displacement with reduction: reciprocal clicks
Anterior disc displacement without reduction: clicks have stopped, limited opening range and referred to as “closed lock”
Posterior disc displacement: cant close mouth “open lock”, can occur after prolonged dental procedures when lateral pterygoid becomes overstretched
What are normal ranges for depression/elevation of mandible?
Elevation (closing): teeth approximation
Depression (opening): maximum 40-50 mm= 4 fingers; functional range 35 mm= 3 fingers
What are kinematics of depression?
Rotation of condyle dominates first 25 mm
Condyle translation dominates 25-35 mm
What are normal ranges for protrusion/retrusion?
Protrusion: 6-9 mm; mandible and disc translate anterior and inferior
Retrusion: 3 mm; mandible and disc translate posterior
What is range for lateral deviation and kinematics?
1/4 of opening range
Rotation/spinning ipsilateral condyle and horizontal translation of the contralateral condyle
What does muscle imbalance mean to you?
imbalances of forces, muscle still strong but inefficient
What muscles have different roles?
yes. mobilizers, stabilizers, power
How does pain change muscle function?
if muscle stops working the pain inhibition will keep going
What happens to muscle if it’s chronically used in shortened position?
in mid range it will be strong
What happens to a muscle chronically used in a lengthened position?
Will produce more torque but it’s not being used in optimal position
What are muscles of mastication?
masseter, temporalis, medial pterygoid, lateral pterygoid, suprahyoid, infrahyoid
What are 4 functions of masseter
1) elevation- bilateral
2) protrusion- bilateral superficial fibers
3) retraction- bilateral deep fibers
4) ipsilateral lateral deviation- unilateral
Where does superficial versus deep muscles of masseter originate and insert?
Superficial: anterior 2/3 of zygomatic arch to lateral border of mandibular angle
Deep: posterior 1/3 zygomatic arch to superior border of mandibular ramus
What are functions of temporalis?
elevation- bilateral
retraction- bilateral
ipsilateral lateral deviation- unilateral
What is origin and insertion for temporalis?
O: entire temporal fossa
I: coronoid process and medial border of mandible ramus
What is function of medial pterygoid function?
Elevation- bilateral
Protrusion- bilateral
Contralateral deviation- unilateral
What is origin and insertion for lateral pterygoid?
Superior head
O: great wing sphenoid bone
I: anterior aspect of disc
Inferior head
O: lateral border of lateral pterygoid plate of sphenoid bone
I: condylar neck
What are functions for superior and inferior head of lateral pterygoid?
Superior (stability): contract eccentrically during mouth closing to monitor disc position and avoid displacement
Inferior (mobility): acting alone produces depression of mandible during mouth closing
What are functions of the suprahyoid?
Together= floor of mouth
swallowing: elevate and move forward hyoid to widen pharynx and close respiratory passage
When hyoid is fixed suprahyoids produce depression and retrusion of mandible
What are functions of infrahyoids?
together stabilize the hyoid bone to form a firm base for suprahyoid muscles
what are O and I for anterior belly of digastric?
midline inferior mandible to hyoid
What are O and I for posterior belly of digastric?
hyoid bone to mastoid notch of temporal bone
What are O and I for mylohyoid?
mylohyoid line along entire length inner mandible border to hyoid bone
What are O and I for geniohyoid?
lies superior to myolohyoid and goes from mandible to hyoid bone
What are O and I for stylohyoid?
styloid process to hyoid bone
What are O and I of infrahyoid muscles?
Sternohyoid, sternthyroid, thyrohyoid, omohyoid: originate on inferior hyoid bone and insert on sternum, thyroid cartilage, scapula
What do supra hyoid and infra hyoid muscles do?
function in speech, swallowing, and tongue movement
What muscles are involved in elevation of jaw?
masseter, temporalis, medial pterygoid, superior fibers of later pterygoid
What muscles depress jaw?
inferior fibers of lateral pterygoid, supra hyoids, infrahyoids, gravity
What muscles protrude jaw?
superficial masseter, medial pterygoid, lateral pterygoid
What muscles retrude the jaw?
deep fibers of masseter, temporalis, suprahyoids
What muscles do lateral deviation of jaw?
ipsilateral temporalis and masseter, contralateral medial and lateral pterygoids
How are muscles of jaw innervated?
Branches of mandibular division of trigeminal nerve
Anterior and medial regions of TMJ innervated by deep temporal nerve and masseter nerve
Posterior and lateral regions TMJ innervated by auriculotemporal nerve
What are parts of subjective exam and patient history for TMJ?
Mechanism, history of treatment, location and type of symptoms, aggravating factors, easing factors, symptom patterns, functional limitations, disability
What are TMD symptoms?
jaw pain, limited opening, popping, clicking, locking, headaches (tension, cervicogenic, migraines), dizziness, ringing in ears/ear pain or fullness in ears, swallowing difficulty
What are symptoms up the kinetic chain?
Neck pain, shoulder pain, thoracic pain, NT or pain in UE, fatigue/malaise, feeling of weakness, depression
What are TMD activity limitations?
pain with eating, chewing, talking Limited ability to work Limited social activities Inability to exercise Stress/depression
What do you look for in objective exam for TMD?
resting posture, asymmetries, natural movement patter, range of TMJ, natural movement pattern and range of cervical spine, thoracic spine, shoulders, restrictions, muscles lacking extensibility, muscles with trigger points, neuro exam, muscle spasms inpresence of pain, myotome deficits, change in length tension curve, muscle imbalance, central sensitization, fearful of movement
What is PT management for TMD?
Mobilize structures and stabilize uncontrolled motion
Educate. Educate,
Empower patients with self management strategies
Concise exercise programs targeted to specific muscle roles
Address contextual factors
Coordinate care with other providers
What is ideal exercise prescription?
1) Postural control exercises for kinetic chain
2) low threshold postural training NOT high threshold load training
3) work on improving movement patterns
4) work on isometrics to recruit slow motor units
5) give patients ideal stretching and trigger point stimulation options
6) address kinetic chain
7) give patients things they can incorporate into their daily life and provide pain control
What are common misconceptions in TMJ treatment?
mobilize all patients it's just restriction of upper C-spine you just need to stretch PT can't help They are crazy patients Patients need braces or surgery
