TMJ Flashcards
TMJ joins it a ___ going
Gliding
Describe the TMJ joint
Convex articular condyle of the mandible
Concave articular fossa on the squamous portion of temporal bone
The TMJ joint is separated by a what
Fibrocartilaginous articular disc (meniscus)
What are the three parts of the fibrocartilaginous articular disc
Thick anterior band
Thin intermediate zone
Thick posterior band
Meniscus of TMJ with mouth closed
The condyle is separated form the articular fossa Kd the temporal bone by the thick posterior band
Meniscus with mouth open
The condyle is separated from the articular eminence of the temporal bone by the thin intermediate zone
Muscles of mastication
Digastric, suprahyoid, left lateral and medial pterygoids, temporalis, masseter
What do digastric, suprahyoid do
Depress mandible (infrahyoid stabilizes hyoid bone) initially, then pterygoids depress jaw
What do left lateral and medial teratoid do
Move mandible lateral and forward to the right
What do temporalis, masseter, medial pterygoids do
Close jaw tightly
What does buccinator do
Approximates lips and compresses cheeks (blowing)
What does depressor labii inferior do
Protrudes lower lip (pouting)
What does depressor anguli oris and platysma do
Draw corner of mouth down
What does mentalis do
Draws tip of chin upward
What does orbicularis oris do
Approximates and compresses lips
What does zygomatic minor do
Protrudes upper lip
What does levator anguli oris do
Lifts upper border of lip on one side without raising lateral angle (snarl)
What does zygomaticus major do
Raises lateral angle of mouth to smile
What does risorius do
Approximates lips and draws lips and draws corners lateral
Grimace
Frontal belly of occipitofrontalis
Wrinkle forehead, raise eyebrows
Platysma
Tense skin of neck
Signs symptoms
Cpehalgia-misdiagnosed as migraines
Otalgia
Neck pain
Eye pain
Shoulder and back pain
Tinutis
Dull ache worse with chewing
Difficulty opening mouth
Click crepitans(jaw click usually present with disc displacement, but by itself non diagnostic)
Lateral deviation of jaw
Spasm within facial muscles
Onset of TMJ symptoms may correspond with onset of stress or added stressors
1 retrospective study of 4528 patients with TMD with pain, ear discomfort, headache, TMJ discomfort or dysfunction
Other symptoms
Neck pain
Eye pain
Arm back pain
Dizziness
TMJ and nocturnal bruxism
Controversial
Jaw clenching
Anxiety and psychosocial stress
Does not interfere with treatment in most cases
-although a severely distributed capacity for interpersonal relationships is associated with poor prognosis
Types of TMJ dysfunction
Opening click
Closing click (reciprocal clicking)
Inability to fully open jaw (close locked)
Inability to close if TMJ symptoms are bilateral
Crepitus and grating
Fusion of joint (ankylosis)
What causes jaw click
*Disc displacement after disc thins or is stretched
Adhesions
Uncoordinated muscle action of pterygoid
Tear or perforation of disc
Osteoarthritis(more likely to have crepitus)
Occlusion imbalance (less likely
Where will we be interfering for TMJ dysfunctions
Pterygoids, masseter, temporalis
Trauma to cause TMJ dysfunction
Direct, whiplash, third molar extraction, intubation
Left deviation
Right medial and lateral pterygoid dysfunction
Right deviation jaw
Left medial and lateral pterygoid
A direct blow with closed mouth
Posterior capsule injury
Malocclusions
Deviation from nl contact of maxillary and mandibular teeth
Class 1 malocclusions
1st molars nl, problem elsewhere
Class 2a malocclusions
Lower 1st mo;at post to upper to greater degree (larger overbite)
Class 3 malocclusions
Lower 1st molar ant to upper get mandibular protrusion (underbite)
Why get malocclusions
Muscle strain (oral habits, postural/work, sports)
MSK problems
SD TMJ
Compensatory changes
Developmental abnormalities (condylar hypoplasia/agenesis)
Mood disorders (anxiety, depression, PTSD, history of abuse)
Endocrine
Hypocalcemia (chvostesks and trosseau)
Intracapsular
Infection RA OA Gout Metastatic CA Articular disc displacement
Extracapusular
Myofascial pain of mastication muscles
- TMJ myofascial pain syndrome
- TMJ dysfunction syndrome
- TMJ syndrome
NIH preferred terminology
-TMJD-temporaomandibular muscle and joint disorder
Possible risk factors TMK
Contradictory association with hyperlaxity
Neck trauma(severe TMD symptoms in 89% of patients c/o whiplash associated symptoms compared to 18% of controls
Female hormones
Bruxism and clenching
Contradictory evidence about associated with occlusion
Up to 75% of TMD may suffer from psychogical abnormalities
Factors not associated with risk of TMJ
Genetics, orthodontics
Epidemiology TMJ
Affect 20% of Americans
Women
#2 cause of facial pain (HA is 1)
What population gets TMJ more
RA
53094%
Osteopathic evaluation for TMJ
Cranial
C spine
Scoliosis
Leg length (innominate, sacrum, SI joint)
Palpate joitns for ___
Crepe tans/clicks
Palpate mastication muscles
1 side may be tender
Ranges of motion
Active-patient opens mouth 3-6 cm, laterally 1-2 cm, and then retracts and protrudes mandible
Observe jaw movements for deviation
Passive ROM
Gloves-move pots jaw medially and laterally(compare ROM on both sides)
Observation TMJ
Cavities, suspicious lesions in mouth, teeth alignment (tongue blade for bite)
Facial asymmetry
LOOK FOR SYMMETRY
Ok
When should you suspect TMJ
Abnormal mandibular movements
Decreased ROM of TMJ
(Normal functional opening is 35-55 mm. Functional opening on TMD puts usually <25 mm and very often associated with pain)
Muscles of mastication tenderness
Pain with dynamic loading
Bruxism(look for signs of tooth wear)
Postural asymmetry (observe posture, assessing for slouching or a preference to lean to one side)
Neck and shoulder muscle tenderness
Normal cranial nerve examination
Differential diagnosis TMJ
Migraine related disorders (Carotodynia)
Inflammatory diseases (infection, RA, giant cell arteritis)
Dental problems (posterior teeth support loss)
Neuralgia (trigeminal , glossopharyngeal)
Parotid gland disorders
Lymphoproliferative
Microbiology and pathology TMJ
C tetani-lock jaw Odontogenic cysts Sclerosing osteomyelitis of garre Monocystic fibrous dysplasia Acromegaly-enlarged jaw-prognatism
Medical side effects TMJ
Steroids-avascular necrosis
Bisphosphonates-osteonecrosis of the jaw
Eagles syndrome(stylohyoid syndrome)
Elongated styloid process
MOTHRR
Medication OMM Testing Holistic/humanistic Referrals Return visit
Radiology for TMJ
Not helpful really But do if suspect dental problems Patient with severe symptoms that don’t improve with conservative treatment tactics Concern for alternative cause Recent, severe trauma
Peripheral radiographs can r/o _ problems
Tooth
MRI
See position and shape of disc
MRI alone not significant unless TMJ movement is restricted or there is clinical suspicion for a disc out
MRI not for evaluation of muscle pain
-disc commonly displaced in asymptomatic patients
Disc displacement Sx
MRI showed
No Sx of TMJD
33% had displaced discs
Level 1 TMJ interventions
Cognitive behavioral therapy for chronic TMJ reduces activity interference, pain and depression at 1 year
TMJ level 2 interventions
OMT, exercise emitriptyline, glucosamine sulfate for OA of tmj, benzodiazepine, Botox, acupuncture, OMT, NSAIDS, hypnorelaxation, oral habit reversal treatment, cognitive behavioral skills training plus biofeedback,, physical self regulation, therapeutic exercise
Level 3 TMJ intervention
OMT Biofeedback alone Surgery Occlusal splints Occlusal adjustment Intra articular corticosteroid inj PT
OMT help TMJ
Didn’t improve it
But OMT associated with less NSADIS and muscle relaxant use
How can we holistically fix
Change head posture, sleeping position , aggravating parafunctional oral behaviors (nail biting, pen chewing)
THE MINIMUMGOAL FOR OPENING THE JAW IS TO BE ABLE TO FIT THE KNUCKLES OF THE INDEX AND MIDDLE FINGER BETWEEN THE ___
TEETH
Retraining
Place the pads of your fingers over your chin
Open your mouth comfortable and slid your jaw forward as far as it will comfortable go
Press your jaw into your finger pads with a gentle pressure
Hold this as you inhale deeply
Upon exhalation allow your mouth to close comfortable
Repeat 3-5 times and do it at least 3 times a day
Retraining lateral deviation
Place hand on mandible on side toward which the jaw deviates
Place the other hand on the opposite cheek bone
Apply enough pressure on these areas to illicit a gentle stretch as you open your mouth
Then close your mouth maintaining the same pressure
Do daily until full relief is obtained, then perform it 2-3 times a week
Acupressure
Insert your clear pinky finger into your mouth between your cheek and gum
Slide your finger along your gum line, above your teeth, until your finger falls into a deeper recess behind your teeth, but in line your gums
Lean your head upon your finger until you experience a sligh discomfort
This discomfort will subside and you will be able to lean more and more into your finger
Do this 2-3 times a day until the symptoms have gone
Deep presssure
Sometimes you may find very sensitive tender points in the cheek muscles
By applying a deep and steady pressure these points will disappear
You don’t haven’t massacre yourself to be successful just press on the point to illicit the feathers adage of pain and follow that edge until it disappears
Self massage
Use the pads of your fingers to feel around your cheeks above the engles of your jaw with a kneading, circular motion
Any tension or Robey sensation that you feel you should massage away
Temporalis self treatment
Use hot packs or a scarf to warm area for 12-30 minutes
Stretch with pinky finger pads placed firmly just behind the hairline and the rest of the fingers in the hair around the ears, apply traction towards the sky
Open and close the mouth slowly while maintaining the traction 5 times
Repeat 2-5 times
Acupressure
Apply pressure to the feathers edge of discomfort
Temporalis retraining
Open your jaw maximally
Press your index finger pads down against your jaw in an effort to open it more
Close your mouth gently against your fingers for 5 sec
Upon relaxing allow your fingers to draw your jaw open more
Repeat 3-5 times
How can adjust diet for TMJ
Decrease chewing with different foods
Referred
Dental surgeon
Oral devices
Surgery
Surgery /arthroscopy indication
Significant pain and dysfunction
Exhausted all conservative measures
Poor prognosis
Psychiatric factors
-have prolonged use of opiates, benzodiazepines, alcohol, other drugs
