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Ortho > TMJ > Flashcards

TMJ Flashcards

1
Q

What is the difference between CR and CO?

A 
CR = condyle in the fossa with a normal loss-disc-condyle relationship
CO = condyle placement while teeth are together
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2
Q

What percentage of people have CR=CO? is this a problem?

A

about 33% have CR = CO

- it can become a problem, but only 5% of people have TMD related pain (case in which it would be treated)

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3
Q

What is TMD?

A

A collective term embracing disorders of the masticatory and cervical musculature, the TMJ’s and associated structures, OR BOTH

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4
Q

What does myofacial TMD usually involve?

A

Masseter and pterygoids

  • there are 12 m’s that influence mandibular motion, but those are the most problematic
  • all attach primarily to condyle/ ramus and elevate the mandible (incl. temporalis)
  • known as the supramandibular group
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5
Q

What m’s are included in the inframandibular group?

A 
4 suprahyoids:
-digastric
-geniohyoid
-mylohyoid
-stylohyoid
4 infrahyoids:
-sternohyoid
-omohyoid
-sternothyroid
-thyrohyoid

All depress the mandible

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6
Q

What is the most unstable part of the TMJ?

A

restrodiscal tissue

  • Attaches the articular disc to poserterior part of the joint
  • Not a lot of tough collagen, highly vasuclarized, highly innervated
  • With time, disc slips forward
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7
Q

How much mandibular depression is due to rotation and translation?

A
  • Rotation = first 20-25mm

- Translation = last 15-20,,

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8
Q

What is the significance of location of pain in TMD?

A
  • Muscle problem = pain in m location

- joint problem = pain right IN the joint

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9
Q

How do you distinguish a true closed lock from m tension/spasm?

A

Closed lock = hard end feel

M guarding = you can push beyond the “end” range and open the jaw more

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10
Q

What are causes of non-articular TMD (due to muscle)?

A
  1. Muscle spasm
  2. Myofascial pain and dysfunction (MPD)
  3. Fibromyalgia
  4. Myotonic dystrophies
  5. Myositis Ossificans progressiva
  6. Growth disorders
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11
Q

What are the causes of articular TMDs?

A
  1. Noninflammatory arthropathies: Primary OA, Secondary OA, Internal derangement (loose disc), Bone/Cart disorders with articular manifestations, and JOINT ANKYLOSIS
  2. Inflammatory arthropathies: Synovitis, Capsulitis, RA, JRA, Seronegative polyarthritis, Ankylosing spondylitis, Psoriatic arthritis, and Infectious arthritis
  3. Neoplasm: Pseudotumors (synovial chondromatosis), Benign (chondroma, osteotoma), Malignant (primary, metastatic)
  4. Diffuse connective tissue disorders
  5. Growth disorders: Developmental (hyperplasia, hypoplasia, dysplasia), and Acquired (condylolysis)
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12
Q

What are the nonsurgical management methods of TMD?

A
  1. Diet modification: Full liquids, Pureed (Mashed potato consistency)
  2. Moist heat (as much as possible)
  3. Splint therapy - brings mandible forward, resulting less m engagement
  4. Dental equilibration: attempt to make CR = CO
  5. Orthodontics
  6. Medication: NSAIDS, Steroids, M relaxants, Analgesics (generally not prescribed), anxiolytics, antihistamines, antidepressants, local anesthetics (inj into TrP)
  7. PT
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13
Q

Why will splint therapy work for only 50% of people and it will worsen problems in 50% of people?

A
  • 50% of people’s TMD will subside with a muscle guard

- 50% will get worse because they use it as a chew toy; splint built by dentists causes glide

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14
Q

What is the acute flare-up protocol for non-surgical management of TMD?

A
  1. Mashed potato consistency diet for 2 weeks
  2. NSAIDS around the clock for 7-10 days
  3. Muscle relaxants for 10-14 days
  4. Splint wear full time
  5. Warm compresses as much as possible
  6. Physical Therapy
  7. Behaviour / Stress Modification
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15
Q

What is brisemont procedure?

A

forced manipulation under general anaesthesia, fully paralyzed, for diagnostic and therapeutic reasons—eg. Ankylosis
- Allows for physical exam without m guarding

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16
Q

Why does Botox only work temporarily?

A

habits haven’t changed

  • TrP develops in another place of m
  • generally not used, saline injections yield similar results for less money
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17
Q

Acute closed lock treatment: Injects fluid into joint space and flushes it out; Basically a lavage in the joint space; Reduces inflammatory mediators; Sometimes diagnostic; gives idea about how joint is functioning

A

Arthrocentiesis

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18
Q

What is surgical management of TMD?

A
  1. Arthrocentesis - For acute closed lock (less than 3 months) or inflammatory purposes
  2. Arthroscopy - diagnostic, can do arthrocentesis at same time, disc repair and lysis of adhesions
  3. Discectomy without replacement
  4. Discectomy with replacement
  5. Disc repositioning
  6. Disc repair
  7. Condylotomy (re-shaping the condyle)
  8. Condylectomy (removing condyle)
  9. Eminectomy (Shaving the articular eminence to make it more flat)
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19
Q

Which way will the jaw deviate if there is a broken condyle or condylectomy?

A

jaw will deviate to ipsilateral side

20
Q

Composed of the mandibular condyle and synovium attached to the distal aspect of the disc; Joint capsule is taut in the inferior compartment to allow for pure rotation of the condyle in the fossa; Initial motion of jaw opening occurs in the inferior compartment as pure rotation

A

Inferior compartment of the TMJ

21
Q

Composed of the temporal fossa/eminence and the superior synovium attached to the disc; Joint capsule is loose in the superior compartment to allow for translation; Translation of the condyle on the eminence occurs after rotation; Late joint motion usually occurs here

A

Superior compartment of the TMJ

22
Q

This limit limits extreme opening and provides prodection for blood and nerve supply

A

posterior ligament

23
Q

_______ provides stability by attaching to anterior
aspect of disc. _____ and _____ ligaments including the collaterals attach the
disc to the condyle.

A

Anterior capsule; Medial; lateral

24
Q

protects the superior joint structures and assists in

condylar translation while protecting at maximum opening

A

temporomandibular ligament

25
Q

What are the TMJ’s check reign ligaments in extreme opening?

A

Stylomandibular and sphenomandibular

26
Q

Lateral excursion results in [ipsi/contralateral] spinning and [ipsi/contralateral] translation

A

ipsilateral spining;

contralateral translation

27
Q

Mover actions of:

  • Temporalis
  • Lateral pterygoid
  • medial pterygoid
  • masseter
  • digastric
  • hyoids
A
  1. Temporalis – guides biting motion to close the jaw and laterally deviates jaw – cn 5
  2. Lateral pterygoid – depresses and protrudes the mandible and guides disc movement by pulling the condyle and disc forward – CN 5
  3. Medial pterygoid – elevates or closes jaw – CN 5
  4. Masseter – initiates elevation of mandible and is considered the strongest elevator of the jaw (Muscle of mastication) – CN 5
  5. Digastric muscles pull or depress the mandible inferiorly – Anteroir belly (CN5) – Posterior belly (CN7)
  6. Hyoids initiate jaw opening.
28
Q

What is the “position of rest”

A
  1. Slightly open (teeth NOT touching)
  2. Lips together
  3. Tongue lightly on the roof of the mouth
29
Q

Created by posterior rotation of cranium and loss of cervical lordosis.; Creates muscle tension and tissue entrapment; Less than 20 mm of space noted between occiput and C2 (2 fingers in width); Changes jaw positioning by causing mandibular retraction and distal occlusion; This creates muscle overuse and tension, thereby changing jaw mechanics.

A

Mechanical entrapment neuropathy

30
Q

what are the components of the craniomandibular system?

A

cranio-cervical joints and craniomandibular joints

  • Neck and jaw position need to be evaluated together when considering facial pain.
  • Cervical spine positioning and muscle tightness effect jaw mechanics and vice versa.
  • Most important area of examination in the cervical spine is the suboccipital region including C2
  • Neck pain experienced in up to 70% of TMD cases reported
31
Q

What stage of joint derangement are:

  • Disc displacement/ dislocation with reduction (reciprocal click)
  • Disc location without reduction (closed lock)
A
  • Disc displacement/ dislocation with reduction (reciprocal click) = Stage I-II
  • Disc location without reduction = Stage III
32
Q

What are the inflammatory processes that can occur in TMD?

A
  1. Retrodiscitis – irritation of the posterior aspect of the joint
  2. Capsulitis and synovitis – will cause pain due to swelling irritating nerve tissue
  3. Arthritis (stage IV-V)
33
Q

Thought to result from excessive or premature translation of condyle; Parafunction causes microtrauma to the disc and ligamentous tissue; Mouth breathing leads to an increase in muscle activity and changes jaw positioning

A

Hypermobility

  • Hypermobility creates anterior disc migration and possible synovium trauma.
  • Ultimately a vicious cycle is created
  • Almost 80% of those with TMJ hypermobility and parafunction will develop problems versus only 16% for those that have hypermobility alone
34
Q

When assessing pain in the synovial folds, what does anterior vs posterior pain represent?

A
  • Anterior pain is an acute response to inflammation

- Posterior pain is a longer standing problem

35
Q

When pain mapping what does Pain # 1, 4, 5, 7, 8 represent?

A

Pain #1 usually occurs early in dysfunction.
Pain #4 usually due to malocclusion.
Pain #5 indicates start of disc displacement.
Pain #7 start of degenerative process.
Pain #8 posterior joint compression.
- #1 = anterior = acute and more concerning

36
Q

What ratio relationship should there be between opening: lateral excursion: protrusion?

A

4:1:1

37
Q

As the __________ tightens rotation ends and translation begins.

A

temporomandibular ligament

38
Q

What are S and S for muscular TMD that need to be investigated?

A
  1. Jaw clicking
  2. Headaches
  3. Facial pain
  4. Jaw locking
  5. Ear pressure
  6. Ear pain
  7. Ear ringing
  8. Tooth sensitivity
  9. Muscle tension
  10. Malocclusion = not coming together naturally and normally
  11. Jaw deviation
  12. Neck pain
  13. Suboccipital tenderness
39
Q

What indicates a shorter upper lip?

A

upper should cover ¾ upper teeth when smiling

- short upper lip – may work hard to keep upper lip down

40
Q

What should you palpate during your examination?

A
  1. Masseter
  2. Lateral Pterogoid – just below the zygomatic arch w/middle finger and
    pointer finger; myofascial release
  3. Temporalis Tendon – just superior to zygomatic arch
  4. Intraoral Palapation – he doesn’t do because they HURT
  5. Anterior versus posterior TMJ
  6. Laterally Deviate, then feel condyle of contralateral side – anterior and posterior,
    assess for pain
41
Q

What are PT treatments for TMD?

A
  1. Education - parafxn’l habits
  2. Proprioceptive training
  3. Postural correction
  4. Manual therapy
  5. Relaxation training
  6. Stabilization exercises
  7. Flexibility and ROM
  8. Modality management
42
Q

What are the proprioceptive training used in treating TMD?

A
  1. Rest positioning – The tip of the tongue resting gently against the roof of the mouth at rest. - habit
  2. Controlled opening – Proprioceptive feedback from the tongue to stabilize for pure rotation in the joint.
    #1 exercise
43
Q

What are the manual therapy options for treating TMD?

A
  1. Soft tissue mobilization
  2. Joint glides
  3. Long axis distraction
  4. Manual stabilization training - isometrics
  5. Cervical spine mobilization and postural correction
44
Q

What are the modality options for treating TMD?

A
  1. Ultrasound - Want small sound head; Frequency of 3 MHz
  2. Phonophoresis
  3. Iontophoresis - If inflammatory process is still present
  4. Electrical Stimulation (TENS)
  5. Low-Level Laser (he doesn’t think this makes a difference of low level vs laser alone)
  6. Biofeedback - Visual, auditory, etc to relax masseter for ex
  7. Hot and Cold Therapy
    - Pain at the end of the day, talk a lot = Ice massage – 5 mins on, 5 mins off, etc
    - Contrast, heat/ice
    - Wake up in the morning and have pain = Heat – could have some clenching etc
45
Q

What % of pt’s seen by PTs are hyper vs hypo mobile?

A

hypermobile = 50%

- hypomobile pts are the result of hyper that led to ADD w/o reduction

Ortho (10 decks)

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