1

Physical Therapy to Improve Successful

Orthodontic Outcomes in Patients with TMD

Presented by:

Heather Salyers, MPT

1. Recognize the signs and symptoms of TMD

2. Appreciate the relationship between TMD and

poor postural alignment, and how PT can assist in

restoration of an optimal bite with minimal excessive

mandibular muscle tension.

3. Make an appropriate referral to a qualified

Physical Therapist

Learning Objectives

Is TMD in your radar? It should be!

“In everyday clinical practice, orthodontists frequently are

confronted with patients presenting with not only the

various orthodontic malocclusions, but also the clinical

signs and symptoms of TMD.” [Ref 40]

Although the research hasn’t found that orthodontics can

be attributed to causing TMD, there is a lot of interest in

how best to manage orthodontic patients that have or

develop TMD. I came across several articles proposing

that TMD be included in the curriculum of orthodontic

post-graduate programs. [Ref: 39, 48]

2017 Review of Literature Univ of Athens, School of

Dentistry:

Prevalence of TMJ Dysfunction

One in 6 children and adolescents have

clinical signs of TMJ disorders. [Ref:49]

A review of the literature estimates

that 15% to 19% of adults have TMD

requiring treatment.[Ref :6]

Females are 3 to 9 times more likely

to have TMD than males. [Ref: 7]

[1]

TMD can be present at any age, but is

more prevalent during adolescence, and

increases with age into the 20’s. [Ref: 40,41].

Contributing Factors to TMD

Trauma to jaw

Parafunctional behaviors:

• bruxism/clenching

• nail biting

Emotional stress/Psychosocial issues

Malocclusion

Craniofacial Deformities

Obligate mouth breather

Playing wind instrument or violin

Pain with chewing, yawning, talking

Jaw catching, locking, subluxing

Restricted mouth opening

Signs and Symptoms of TMJ dysfunction:

Change in bite (occlusion)

Fatigue/soreness of jaw/face muscles

Ringing in ears

Ear feels clogged

Clicking/noises of TMJ

Headaches

2

Screening Tool for TMD

1. Do you have pain in your temples, face, TMJ or jaw once a

week or more?

2. Do you have pain when you open your mouth wide or chew,

once a week or more?

From: Nilsson 2007 “Reliability, validity, incidence

and impact of TMD in adolescents” [Ref:41]

Test-retest reliability of 0.83 (kappa) was found for the

two questions. Sensitivity was 0.98 and specificity 0.90

Clinical Exam to Assess for TMD

1. Palpate joint and mandibular muscles

2. Observe mouth opening kinematics.

3. Is mouth opening restricted?

4. Look for damage to teeth from bruxism.

5. Utilize Diagnostic Imaging (CBCT, MRI)

to assess status of condyles and discs.

1. Palpate joint and mandibular muscles

Palpate TMJ as mouth opens.

As condyle glides anteriorly,

palpate retrodiscal space.

Is it painful?

Palpate along mandibular muscles for any

tenderness, excessive tension or trigger points.

2. Observe mouth opening kinematics

Normal - rotation and anterior gliding without mandibular

deviation or deflection

• Premature thrusting forward of mandible

• Deviation (c or s-curve) with opening and/or closing

• Deflection to one side with opening and closing

Abnormal Kinematics:

3. Is mouth opening restricted?

There is a wide variation amongst individuals as to their

“normal” amount of mouth opening. It can range from 39

to 65 mm. [Ref: 9]

In my experience, the minimal amount of mouth opening

required to be functional is typically 35 mm.

Hypermobility = Lax Ligaments

Score of >4/9 is indicative of hypermobility

Beighton scoring system for joint hypermobility

3

4. Look for damage to teeth from bruxism

Fit with a night time appliance to protect teeth

Bruxism is believed to be present in up to 20%

of the general adult population, and is present in

66% of people with TMD. [Ref: 10]

5. Utilize Diagnostic Imaging

(CBCT, MRI)

CBCT visualizes: MRI visualizes:

bone soft tissue

Condyle’s position in fossa Discal displacement

Active breakdown of condyle Effusion

Integrity of TMJ Bone Marrow Disorders

Differential Diagnosis

Submandibular or parotid gland stone or tumor

Sx can mimic TMD, but pain occurs with salivary gland

stimulation, without any jaw movement. (test w/ sour candy)

If infected, sx include swelling and bad taste in mouth. Also

may see pus as sweep along parotid gland.

Image: Wilson et al 2014

The often complex contributing factors to TMD necessitate

a collaborative approach for successful treatment of these

patients..

A patient with TMD may require the services of a physician,

dentist, orthodontist, physical therapist, maxillofacial surgeon,

psychologist and pain management specialist. [Ref:13,14.,23-26,29.]

Why refer to Physical Therapy?

Since TMD is a musculoskeletal dysfunction, it falls within

the scope of practice of Physical Therapy. A review of the

literature supports Physical Therapy as a successful adjunct in

the management of TMD. [Ref: 13,14,18, 23, 25, 29,30,37,45,51,52]

When to refer to Physical Therapy?

Limited mouth opening due to close-locked or

muscle spasm.

Complaint of Headaches

Forward head and rounded shoulder posture

Tenderness to palpation of muscles of mastication

Neck pain and muscle tension

Pain with jaw functional activities

As Physical Therapists, we are musculoskeletal specialists.

We are trained to recognize abnormal postures and body mechanics.

Basic level of TMD training received in PT school.

Advanced training comes after you graduate if decide

to specialize in treating TMD.

4

For my associates and I, our TMD training is based primarily on

the works of Mariano Rocabado, PT. We received this training

as part of our post-graduate studies to enhance our skills as

manual orthopedic therapists.

Ongoing continuing education in various manual therapy

techniques, as well as our collaboration with dentists,

orthodontists and oral surgeons, allow us to grow and evolve as

TMD rehab specialists.

Training as a TMD Rehab Specialist

Pic of staff from website

Our View of TMD – The Big Picture

As PT’s, we are trained to look at the body as an

integrated system. No joint operates in isolation from

the rest of the body, and this is especially true when

looking at the TMJ.

What other 2 regions of the body have muscular

connections to the head and jaw?

Answer: the Neck and Shoulder Girdle

What bone links them?

Answer: the Hyoid bone!

Image: Hislop, H et al 1995

The posture of the head, neck

and shoulders will alter the

muscle length and tension

acting on the hyoid bone,

which alters the muscle forces

around the jaw. [Ref: 14]

Hyoid

How prevalent is forward head posture?

It’s estimated that 90% of the

United States population exhibits

forward head posture of 5 cm or

more!

we just give in to

So, why do we let our heads drift forward? Center of Gravity (C.O.G.) in Ideal Posture

The C.O.G. in ideal posture falls

slightly anterior to the atlanto-

occipital joints. [Ref: 11]

Due to this, the head will fall

anteriorly if the neck muscles

totally relax.

To maintain good head position,

strong posterior neck muscles are

needed to support the weight of the

head against gravity. [Ref:17,18]

Image: Norkin 1992

5

30 lb 20 lb 10 lb The effective weight of your head

increases by 10 lbs for every inch

your head drifts forward!

How heavy can your head feel?

Neck muscle strain

Where the head leads, the shoulders will follow!

This abnormal posture is BAD NEWS, not just for our

shoulders, neck and back, but also for our jaw!

Abnormal postural alignment

directly alters the muscle balance

around the head, jaw, neck and

shoulder girdles.

Abnormal Posture creates Muscle Imbalances

It becomes evident that there is a direct

relationship between craniovertebral

abnormalities and TMD.

[Ref:15,16,31,32,44]

It should now be apparent why the treatment of TMD requires a

broader view and the expertise of other professionals who can

address the muscle imbalances contributing to the pt’s symptoms.

Relationship between Craniovertebral

Abnormalities and TMD

Overview of our TMJ Assessment

Posture Analysis

Assess upper and lower c-spine mobility

Palpate head, neck and jaw musculature

Strength test lips, cheeks, tongue and jaw muscles

Measure jaw AROM and

Assess TMJ mobility (restricted arthrokinematics)

Observe jaw kinematics

Observe and Measure Postural Alignment

Forward head position

Scapular position

Spinal curves

Depressed sternum

Pelvic Alignment

6

Facet joints

C1

C2

C3

C4

C5

C6

C7

Facet joint mobility of lower cervical spine

Alignment of First Vertebra

Assess upper and lower c-spine mobility

Lateral and saggital glides of atlanto-occipital joints

Palpate head, neck and jaw musculature

Our highly developed sense of touch enables us to detect

myofascial restrictions, muscle spasms and trigger points.

Cervicogenic Headaches[Ref:21,22]

Pain originates from the cervical spine and is

referred to the head.

Often associated with restricted mobility of the

upper c-spine.

Brought on by sustained neck posture.

Changes in the muscle occur causing them to

become abnormally painful.

Headache is often unilateral and can be reproduced

by palpation of the trigger point on the side of pain.

Trigger Points

Small, ischemic, tender points in a muscle that when

palpated refer pain to a remote location.

Trigger points in muscles receiving sensory innervation

from C1 through C3 may refer pain to various regions

of the head.[Ref :20]

Image:www.triggerpoints.net

Referred Pain Pattern for Splenius Capitis

Trigger Point

Spasm of the splenius capitis may cause top of

the head headache. [Ref:20]

Image:www.triggerpoints.net

Referred Pain Pattern for SCM

Trigger Point

Image:www.triggerpoints.net

7

Referred Pain Pattern for Sub-Occipital

Trigger Point

Trigger points in the sub-occipitals can cause

headache symptoms around the ear. [Ref:20]

Image:www.triggerpoints.net

Referred Pain Pattern for Temporalis

Trigger Point

Image:www.triggerpoints.net

Referred Pain Zones for Masseter Trigger Points

A. Upper portion

superficial layer

B. Mid-belly

superficial layer

C. Lower portion

superficial layer

D. Upper portion

deep layer

Image:www.triggerpoints.net

Referred Pain Pattern for Medial

Pterygoid Trigger Point

A. External facial

pain area

B. medial pterygoid

trigger point

C. Internal areas

of referred pain

Image:www.triggerpoints.net

Referred Pain Pattern for Lateral

Pterygoid Trigger Point

Image:www.triggerpoints.net

Referred Pain Pattern of Digastric Muscles

Image:www.triggerpoints.net

8

Assess TMJ Mobility

Image: Hertling et al 1996

Measure Jaw AROM

Mouth opening

Measure Jaw AROM

Laterotrusion

Observe Jaw Kinematics

Strength Test lips, cheeks, tongue

and jaw muscles

Image: Hislop 1985

TMJ Dysfunction: Classification

Self-reducing Closed-locked Muscular

Joint noise click None or crepitus None or

crepitus

AROM of

Jaw

Normal or

slightly

decreased

Min of 20-25 mm;

lateral exc to the

opposite side is

decreased

Can be severely

decreased

(<10 mm)

to normal

Kinematics C-curve with

opening &

protrusion

Deviation toward

involved side w/

m/o & protrusion

random

9

Overview of our Treatment Approach

Decrease TMJ Inflammation

Decrease Muscle imbalances by :

soft tissue release

stretching exercises

strengthening exercises

Improve postural alignment

Improve TMJ kinematics

Restore normal TMJ mobility (via JM or stabilization)

Restore normal resting tongue position

Recommend splinting when appropriate

Improve tongue coordination and strength

Posture Improvement in response to

Physical Therapy

I hope you found my presentation helpful and informative.

Thank you

Touch Personal

h

y

s

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c

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l

h e r a p y

& Wellness Center

West Chester Office Plaza 790 East Market Street

Suite 290 West Chester, PA 19382

(610) 696-3305

Fax (610)-696-3306

Screening Tool for TMD

1. Do you experience pain of your ear, temple or jaw when biting, chewing, yawning or talking? 2. Do you awaken with jaw stiffness, fatigue or pain? 3. Does your jaw make noise when you open your mouth or with chewing/talking? 4. Do you have difficulty opening your mouth wide enough to eat or for dental cleanings? 5. Does your jaw ever lock or catch? 6. Has your bite changed recently? 7. Do your jaw/face muscles feel tired with chewing, talking, or singing? 8. Do you get headaches along your temples, around the eyes, or below your cheekbones? 9. Do you get ringing in your ear(s), or feel pressure/fullness in your ear?

Physical Therapy to Improve Successful Orthodontic Outcomes in Patients with TMD AAO 2018

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