TMJ (OCS-A summary) Flashcards
The TMJ is divided into what two compartments, by which structure?
- superior and inferior compartments
- fibrocartilaginous disk
During opening, the condyle ______ in the _______ cavity, and _______ in the _________ cavity.
- rotates in the inferior compartment
- translates in the superior compartment
What are the 3 divisions of the disk?
- anterior
- intermediate (avascular/aneural)
- posterior
What muscles are considered depressors?
- suprahyoids
- infrahyoids
- lateral pterygoid (inferior fibers)
What muscles are considered elevators?
- masseters
- temporalis
- medial pterygoid
- lateral pterygoid (superior fibers)
What muscles are considered protrusors?
- medial pterygoid
- lateral pterygoid
- masseter (superficial fibers)
What muscles are considered retractors?
- masseter (deep fibers)
- temporalis
- suprahyoid
What muscles are considered lateral deviators?
- medial pterygoid (contralateral)
- lateral pterygoid (contralateral)
- temporalis (ipsilateral)
- masseter (to a lesser degree…)
What is considered a normal opening width for the TMJ?
- 3-4 finger widths
- 35 mm is functional
- 40-50 mm is normal
What is considered normal lateral deviation?
- 1/4th the amount of opening
- e.g., 10 mm for a 40 mm opening
What is considered normal protrusion?
- 6-9mm
What is considered normal retrusion?
- 3 mm
What are the considerations for classifying internal derangement of the TMJ?
- whether or not the anterior disk reduces or not
If a pt experiences a click when the open their jaw, and when they close it, what is this indicative of?
- anterior disk displacement WITH reduction
What are often contributing factors to an anterior disk displacement with reduction?
- strong pull of superior lateral pterygoid
- very tight posterior capsule fibers
What are the characteristics of an anterior disk displacement without reduction?
- no clicking
- may have limited, painful opening
- if fully displaced, may have normal, but painful opening
What is the presentation of a fully displaced anterior disk?
- may have normal opening, but it will be painful
What is the presentation of a posterior disk displacement?
- uncommon
- usually occurs after prolonged mouth opening (e.g., dental procedure)
- results in an inability to close the mouth; i.e., open lock
What is the open pack position of the TMJ?
- tongue to roof of mouth
Is TMJ clicking pathological?
- no, it can be a normal variant
Subluxation of the TMJ occurs with over ____mm of opening. Can be associated with connective tissue disorders such as ___________.
- 40 mm
- Ehler’s-Danlos
What are the common causes of an ankylosing TMJ?
- trauma
- RA
- polyarthritic disease
- e.g., some type of inflammatory process
With an ankylosed side of the TMJ, what will opening look like?
- restricted on the ankylosed side with ipsilateral lateral deviation
TMD is associated with what 3 factors/habits/symptoms?
- stress
- headaches
- bruxism
- strong connection between all 4 things
T or F;
Migraine can be triggered by TMJ tension.
- T
What is a pathoanatomical rationale for tension headaches?
- can be caused by postural imbalance w/ forward head posture
- posture creates bias for trigeminal and greater occipital n. irritation
- results in head/face pain
Are cervicogenic headaches usually unilateral or B?
- unilateral
Are cervicogenic headaches and TMD commonly associated?
- yes
What is a proposed cause of cervicogenic headaches?
- cervical alignment issues; e.g., decreased lordosis
What is in the differential with TMD that’s not a headache?
- Temporal arteritis
What may be a clue for temporal arteritis vs TMD?
- can cause claudication; worsening pain during chewing that follows an ischemic pattern
- potential for severe temporal headache
- can create visual changes
How can one differentiate between a capsular vs disk issue with mouth opening?
- Capsular: deviates from midline, but then returns to midline with full opening.
- Disk: deviates from midline and does not return (Deflection)
What is the Cotton Roll Test used for? How does it work?
- differentiating muscle vs joint origin of pain
- biting down with back molars on cotton roll creates gapping/unloading at ipsilateral TMJ, with contralateral compression
- if pt w/ pain on R, bites down with roll on R and pain is alleviated, then likely joint. If aggravated, then likely muscular
What is trismus?
- masseter spasm causing acute lock jaw
- <25mm opening
- occurs with prolonged mouth opening
- TTP at masseter
What intervention should be considered with myofascial TMD?
- cervical mobs
- deep flexor therex
- found to improve pain at rest and with chewing, as well as mouth opening tolerance
What is considered a core component of initial TMD intervention?
- education to prevent fear/anxiety and reduce risk of progression to chronic condition
When is TMJ manipulation indicated?
- acute closed lock
- dislocation
- done by doctor or dentist under anesthesia
What are some primary intervention types for TMJ?
- education
- postural modifications
- behavioral therapy
- cervical mobs
- therex
What are specific exercises that are appropriate for TMJ?
- depends on presentation but…
- deep neck flexor therex
- tongue controlled mouth opening
- TMJ isometrics
What is a key component of TMJ exercises?
- tongue to the roof of the mouth
- opening/closing with tongue at roof
- gentle isometrics with tongue at roof
How is a longitudinal distraction of the TMJ executed?
- pull down in a vertical axis with force directed via the thumbs on the bottom molars
Condylar remodeling exercises are typically used with what type of TMD?
- anterior disk displacement with reduction
What do condylar remodeling exercises look like?
- rubber tubing between incisors
- lateral deviation AWAY (contralateral) to the painful side
- can be w/ or w/o bite force during the deviation
What are the key components to management of myofascial pain disorder?
- multidisciplinary
- behavioral intervention
- education
What is an appropriate outcome measure for TMD treatment efficacy?
- Health related quality of life
What are common comorbidities related to TMD?
- depression
- fibromyalgia
- chronic fatigue syndrome
- IBS
- RA
- chronic headache
What is the Rocabado 6x6 protocol for TMD?
- 6 reps, 6x/day
- Cluck
- Tongue to palate with opening
- Jaw isometrics
- Upper cervical flexion
- Cervical extension with retraction
- Scapular retraction and depression
What are 7 conditions in the differential for TMD that are not tension/cervicogenic headache or temporal arteritis?
- dental caries
- post herpetic neuralgia
- glossopheryngeal neuralgia
- trigeminal neuralgia
- giant cell arteritis (…kind of temporal arteritis)
- maxillary sinusitis
- migraine headache
The following is characteristic of which differential dx for TMD?
- mandibular pain that is worsened by hot/cold food
- dull ache
- visible tooth decay
- Dental caries
- tooth pain can refer to the mandible
The following is characteristic of which differential dx for TMD?
- continuous intraoral or extraoral facial pain
- continuous pain
- can be sharp, burning
- aggravated by light touch or eating
- recent shingles virus
- post herpetic neuralgia
The following is characteristic of which differential dx for TMD?
- unilateral
- deep pain in ear, tongue, tonsils, or cervical region
- episodic, brief intense attacks of shooting electric shock pain
- aggravated with swallowing, coughing, palpation of ear
- glossopheryngeal neuralgia
The following is characteristic of which differential dx for TMD?
- unilateral
- deep pain in head/neck region
- episodic, brief intense attacks of shooting electric shock pain
- can be spontaneous w/o stimulus
- Trigeminal neuralgia
The following is characteristic of which differential dx for TMD?
- Temporal region jaw pain
- sudden onset with continuous pain
- usually dull pain, but can be severe
- may have diploplia, weight loss, polymyalgia rheumatica, fever, malaise
- can result in blindness
- giant cell arteritis
The following is characteristic of which differential dx for TMD?
- dull unilateral or B upper quadrant facial pain
- usually accompanied by nasal discharge or other signs of respiratory infection
- TTP at maxillary and frontal sinus
- maxillary sinusitis
The following is characteristic of which differential dx for TMD?
- temporal or “behind the eye” pain
- photophobia, phonophobia, visual aura
- normal cranial nerve screen
- often throbbing pain
- migraine
- can often be triggered by TMD
