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Chew on this: Evaluation and Treatment of TMJ DysfunctionIPTA FALL CONFERENCE 2019
TRACY PORTER, PT, DPT
Objectives
1. Describe TMJ anatomy and biomechanics.
2. Identify key examination elements.
3. Discuss diagnostic classifications for TMJ dysfunction.
4. Apply interventions specific to a diagnostic classification.
Incidence
10-70%
Women > men
Ages 20-40
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Etiology
Dental procedures Surgical procedures Injury Clenching/grinding Mal-occlusion Missing teeth Arthritic changes Postural imbalances Stress Parafunctional habits Movement dysfunction of the jaw
Presentation
Significant variance in presentation
Interdisciplinary (multi-factorial) approach
Anatomy of the Temporomandibular Joint
https://images.app.goo.gl/zG1auDToqmMFEh5GA
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https://images.app.goo.gl/sgDrm8WiuNrTKKXJ9
https://images.app.goo.gl/ebhGy7XK1mNkzMJz8
Close functional and anatomical relationships between cranial nerves V and VII (sensory and motor)
Sensation on the face is innervated by the trigeminal nerves (V) as are the muscles of mastication, but the muscles of facial expression are innervated mainly by the facial nerve (VII) as is the sensation of taste
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https://images.app.goo.gl/QTKNkGvnjLZmGXd17
Key History Elements
History of s/s – onset, mechanism
Description of s/s – pain location, intensity, description, associated functional limitations (mouth opening, eating, talking etc.)
Presence of joint noise
Stressors
Dental history
Differentials to Consider
Neurological Atypical facial neuralgia - associated paresthesias
Trigeminal neuritis – ages 45-60 most common, unilateral shooting pain, typically brief episodes, may be clustered or random
Bell’s palsy – ages 20-50, associated facial paralysis
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Non-neurological Otitis media
Paranasal sinusitis
Dental infections
Cluster headaches – associated with lacrimation and rhinitis, ipsilateral facial redness, attacks last approximately 45 minutes on average
Temporal arteritis – elevated SED rate, males over 50, skin over temple red/warm
Examination
General observation
Posture
Palpation
AROM
PROM
Accessory motion/movement quality
Muscle performance
Special tests
General Observation
Crossbite: mandibular teeth are lateral to maxillary teeth on one side and medial on the other side
Underbite: mandibular teeth are anterior to maxillary teeth
Overbite: maxillary incisors extend below mandibular incisors when jaw is in central occlusion
Overjet – measure of how far top incisor teeth are ahead of bottom incisors
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Central Occlusion
Posture
Palpation
Cervical musculature
Muscles of mastication
Joint palpation
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Active Range of Motion
Cervical
TMJ Mandible depression – 35-50mm, two knuckles or three fingers
Mandible lateral glide – 10-15 mm
Mandible protrusion – 6-9mm
Passive Range of Motion
Firm end feels expected
Accessory Motion/Movement Quality
Inferior glide
Anterior/posterior glide
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Muscle Performance
Mandible elevators – masseter, temporalis, medial pterygoid
Mandible depressors – lateral pterygoid, hyoid muscles
Mandible protractors – medial pterygoid, lateral pterygoid
Contralateral mandible lateral glide – medial and lateral pterygoids
Muscle Performance
https://www.youtube.com/watch?v=IYisgSo03Ds
https://www.youtube.com/watch?v=QXKnd_yIU2Y
Special Tests
Krogh-Poulsen bite test – ipsilateral pain (muscular); contralateral pain (joint)
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Diagnostic Classification
Heterogenous
Harrison Diagnostic Classification
Axis 1
Masticatory Mm
disorders
Disc Displacements
Joint dysfunction
With normal
opening
With limited
opening
With reduction
Without reduction
with limited
opening
Without reduction
without limited opening
Osteoarthritisarthralgia
osteoarthrosis
Interventions
Postural training
Therapeutic exercise
Manual therapy
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Diagnostic Classification
Hypomobility Arthrogenic
Myogenic
Acute vs. subacute or chronic
Interventions
Acute arthrogenic – education, antiinflammatory modalities, joint protection, passive range of motion, postural correction exercises
Subacute or chronic arthrogenic – education, consider ultrasound, joint mobilization, stretching, postural correction exercises
Acute myogenic – education, antiinflammatory modalities, gentle manual therapy, range of motion, inhibition techniques, postural correction exercises
Chronic myogenic – education, consider thermal modalities, dry needling, manual therapy, stretching, inhibition techniques, postural correction exercises
Diagnostic Classification
Hypermobility Disc
Joint
Acute vs. subacute or chronic
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Interventions
Acute disc or joint – education, avoidance of end range mandible depression, joint protection, antiinflammatory modalities, postural correction exercises
Subacute or chronic disc or joint – education, neuromuscular reeducation, joint protection, postural correction exercises
Case Discussions
References
Armijo-Olivio S, Pitance L, Singh V, Neto F, Thie N, and Michelotti A. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: Systematic review and meta-analysis. Physical Therapy. 2016;96(1):9-25.
Clinical examination of the temporomandibular joint. Elsevier, Ltd. 2013. Harrison A, Thorp J, and Ritzline P. A proposed diagnostic classification of patients with
temporomandibular disorders: Implications for physical therapists. JOSPT. 2014;44(3):182-197.
Lietz-Kijak D, Kopacz L, Ardan R, Grzegocka M, and Kijak E. Assessment of the short-term effectiveness of kinesiotaping and trigger points release used in functional disorders of the masticatory muscles. Pain Research and Management. 2018:1-7.
Rajeskhar H. Physical therapy in temporomandibular disorders. Indian Journal of Physiotherapy and Occupational Therapy. 2015;9(2):198-204.
Reneker J, Paz J, Petrosino C, Cook C. Diagnostic accuracy of clinical tests and signs of temporomandibular joint disorders: A systematic review of the literature. JOSPT. 2011;41(6): 408-416.
Van Grootel R, Buchner R, Wismeijer D, and van der Glas H. Towards an optimal therapy strategy for myogenous TMD, physiotherapy compared with occlusal splint therapy in an RCT with therapy-and-patient-specific treatment durations. BMC Musculoskeletal Disorders. 2017;18:76-92.
