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Temporomandibular Disorders

Anita Gross McMaster University,

Hamilton, CA ���

FUNCTIONAL ANATOMY Part I

TMJ - Lateral view •  complex, modified sellar, bicondylar synovial jt

Articular Eminence

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Axis of Movement

•  3 degrees freedom

•  close pack position •  max opening •  centric relation

•  loose pack position •  1-3 mm opening

•  Capsular pattern

•  ipsilateral deviation

Disc - Lateral View

Biconcave Articular Disc

Coronal View

Collateral ligaments

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TMJ - Ligaments Temporomandibular Ligament

•  horizontal band •  oblique band

Consider which ligament might be stressed with the following directional forces: •  AP •  AP-inferior in 25mm opening •  PA-inferior in max opening

Note: Stress testing TMJ ligaments is hypothetical and not a valid test procedure

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Temporalis

TMJ - Muscles

1

2

3

9

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Craniomandibular Index: Validity Fricton & Shiffman 1987 Reliability of CMI Hatch et al 2002

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Masseter

4 5

6

21

22

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Digastric

7

5

Medial Pterygoid

Lateral Pterygoid

A.

B.

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12

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Palpation Sites

Craniomandibular Index: Validity Fricton & Shiffman 1987

CMI: Psychometric Properties

CMI score ICC CMI Total score 0.875 Muscle Index score •  Jaw muscle: extraoral palpation •  Jaw muscle: intraoral palpation •  Neck muscle

0.856 0.802 0.671 0.813

Dysfunction Index •  Jaw mobility •  Joint sounds •  TMJ palpation

0.808 0.773 0.634 0.666

Interrater reliability

Hatch et al 2002

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Consider pausing for a moment and palpating each muscle •  Extraoral

•  anterior, middle, posterior, insertion of temporalis

•  deep & superfical masseter •  medial pterygoid •  superohyoid, digastric

•  Intraoral •  masseter •  temporalis •  medial pterygoid

View youtube: http://www.youtube.com/watch?v=wtOTI5Yt28w http://www.youtube.com/watch?v=tjBCAkMy13o

TMJ Biomechanics 5 stages of opening and closing (Rocabado)

1.  Rest 2.  Rotation 3.  Functional

opening 4.  Translation 5.  Closure

Normal Opening

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Rest

•  Loosepack •  Connective tissue at rest •  Upper and lower

pterygoids quiet EA

TMJ Rotation

•  Anterior rotation (anterior slide; posterior roll) of the condyle of the mandible on disc until collateral ligaments become taut

•  Lower head of pterygoid is contracting

•  Mandible and disc translate anterocaudal

EA

TMJ functional opening

•  Disc and condyle glide anterocaudal

•  Both heads of pterygoid contract guiding motion

•  Posterior tissue under tension (RDL)

•  functional opening 40mm

EA

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TMJ Translation

•  Full opening •  Disc and condyle glide

to EA •  Further pterygoid upper

and lower contraction •  Posterior tissue taut

EA

TMJ Biomechanics-closing

•  Disc and condyle glide backwards, L.Pt relax

•  Condyle rotates under disc stab by S. Pt.

•  Limited by teeth •  Proprioceptive

stimulation guides mandible

•  Retrodiscal lamina off tension

EA

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Anterior Disc Displacement with Reduction

Disc Displacement without Reduction

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Causes of Clicks

Sounds on opening •  hypermobility –condyle overides meniscus •  inelastic posterior meniscal ligament •  meniscal derangement, partial tear, click at same point each time •  hydrolic action of lubricant •  Articlular surface changes Sounds on closing •  hypermobility – reduction of opening; subluxation •  detached posterior meniscal ligament – trauma •  meniscal derangement Other •  tendon of muscle cross each other and snap •  coronoid process snaps against zygomatic arch

Temporomandibular Disorders

Anita Gross McMaster University,

Hamilton, CA ���

EPIDEMOLOGY & DIAGNOSIS Part 2

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Prevalence •  75% general population have 1 sign •  33% general population have 1 symptom •  7% severe dysfunction / seek help

•  Age 15 to 40 equal prevalence •  Age >40 decreased prevalence

•  Females seek help 3-9x > males

Epidemiology Pretest Probability

of Disorder Type •  ID 31% •  OA 39% •  Myalgia or

myofascial pain 30%

Natural Course •  Transient •  Self limiting •  Frequently without

long term effect •  Click/locking: 4

years •  Locking/pain rest &

function: 1 year

NORMAL ID with reduction ID without reduction/acute ID without reduction/

chronic History None None Positive history of

mandibular limitation Positive history of TMJ noise

Exam A. No reciprocal click B. No coarse crepitus C. Passive stretch ≥40 mm D. Lateral movements ≥7mm E. If S-curve deviation is present, then joint must be silent

A. Reciprocal click or popping present B. No coarse crepitus C. Passive stretch ≥ 35 mm

A. No reciprocal click B. No coarse crepitus C. Maximum opening ≤ 35 mm D. Passive stretch <40mm E. Contralateral movement <7 mm F. No S-curve deviation

A. No reciprocal click B. Coarse crepitus or joint sound other than A.

Tomography A. No decreased translation in ipsilateral condyle B. No osseous changes

None Decreased translation of ipsilateral condyle * Ipsilateral condyle has:

1. Decreased translation, or 2. Positive osseous changes

Diagnostic Classification

Shiffman et al 1989; S 0.97 Sp 1.0

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Consider pausing for a moment and reviewing diagnostic classifications Axis 1 Clinical TMD Conditions •  Muscle Disorders

•  Myofascial pain •  Mysofacial pain - limited opening

•  Disc Displacement •  Disc displacement with reduction •  Disc displacement without reduction

•  Arthralgia, Arthritis, Arthrosis Axis 2 Pain-related Disability and Psychological Status •  A seven-item questionnaire for grading chronic

pain severity •  The depression, vegatative symptoms and

somatization of the SCL-90R •  A jaw disability checklist based on items commonly

used in clinical TMD research

IHS 2003 Dworkin & Le Resche 1992, Dworkin et al 2002 Rammelsberg et al 2003

CLINICAL EXAMINATION Part 3a

Subjective Exam •  Pain location •  Jaw function (eat,

talk, yawn, swallow) •  Joint noise, locking •  Parafunction •  Dental sign &

symptom •  Headache, neckache •  Ear & eye symptoms •  Level of stress

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Investigative Tests

• Xray, panography – not much help • Tomography – rule out OA • MRI (saggital, coronal view) – rule in and out ID

• Arthorgraphy – rule in and out ID

• Blood work

Diagnostic Accuracy Test Sensitivity Specificity Interpretation

For Internal Derangement (ID): Digital palpation and stethoscope: joint sound 0.65 0.81 Rule in ID

Audible joint sound on closing 0.67 0.93 Rule in ID Audible click 0.45 0.85 Rule in ID Audible crepitus 0.19 0.95 Rule in ID Deviation on opening away from symptomatic side 0.23 0.90 Rule in ID

Clinical exam: decreased ROM on opening & translation, deviation toward symptomatic side, click

0.57 0.88 Rule in ID

Clinical exam: > 1of pain, muscle spasm, cramps, headache 0.33 0.93 Rule in ID

Questionnaire: pain in ear 0.88 0.12 Rule out ID Clinical exam: > 1 of pain, joint noise, decreased ROM 1.00 0.48 Rule out ID

Electrothermography 0.86 0.72 Rule out ID Sagittal tomography (helps rule in OA) 0.82 0.68 Rule out ID

Coronal and sagittal MRI 0.88 0.80 Rule in/out ID Dual space double contraxt arthrography 0.88-1.00 0.84-0.96 Rule in/out ID

For Internal Derangement without Reduction (ID-R): Digital palpation & stethoscope: crepitus 0.35 0.97 Rule in ID-R

Audible crepitus 0.35 0.97 Rule in ID-R Clinical exam: restricted ROM, tranlation 0.66 0.81 Rule in ID-R

Clinical History: pain on contralateral movement 0.34 0.93 Rule in ID-R

Questionnaire: pain in front of ear 0.94 0.84 Rule in/out ID-R Clinical Exam: Schiffman et al 1989 0.97 1.0 Rule in/out ID-R For Internal Derangement with Reduction (ID+R): Clinical history: restricted movement 0.38 0.93 Rule in ID+R Clinical history: restricted ROM for opening 0.86 0.62 Rule out ID+R

Digital palpation & stethoscope: joint sound 0.82 0.60 Rule out ID+R

Digital palpation & stethoscope: reciprocal click 0.86 0.79 Rule out ID+R

Digital palpation & stethoscope: reproducible click 0.80 0.84 Rule in/out ID+R

Clinical Exam: Schiffman et al 1989 0.97 1.0 Rule in/out ID+R

Gross et al 1992 (thesis)

Cranial Nerve Quick Scan

CN I (Olfactory): smell coffee eyes closed CN II (Optic): read a sentence 1 eye closed CN III (Oculomotor), IV (Trochlear), VI (Abducent): test eye movements CN V (Trigeminal): resist mm of mastication, - sensation testing 3 branches CN VII (Facial): whistle, wink, close one eye on one side, show teeth. Consider Bell’s palsy. CN VIII (Vestibulocochlear): - hearing is tested by having patient close eyes and rubbing therapists fingers next to one ear and asking patient to indicate which ear; - balance test (Rhomberg or tandom walk) CN IX (Glossopharyngeal) & CN 10: swallow CN XI (Accessary): contract sternomastoid CN XII (Hypoglossal): sticks tongue out, R, L

For detailed CN Scan:

www.neuroexam.com

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Facial Posture

•  Symmetry between biputital, otic, and occlusive lines

•  The face is divided into three equal parts

Bipupital line Otic line Occlusive line

1/3 1/3 1/3

Hair line Bipupital line Nose line Chin line

Postural Evaluation

Forward Head Posture (upper Cx ext; lower Cx flex

Shortening Suboccip & SCM

Compensation Shoulder girdle posture (elevation &forward rotation

Increased elastic tension Suprahyoid & infrahyoid

Change in rest posture - Mandible - Hyoid - tongue

Tightness in throat Difficulty in swallowing

Mandibular pulled Down and back in Relation to maxilla (condyle elevated & retruded)

Altered occlusal contact (initial occlusal contact post to max intercuspated Position)

Muscle bracing

Spasm of stomatognathic muscles

TMJ Dysfunction &

Pain

Increased CNS input

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Temporomandibular Disorders

Anita Gross McMaster University,

Hamilton, CA ���

CLINICAL EXAMINATION Part 3b

Teeth Mesial (anterior)

Distal (posterior)

Upper permanent teeth Lower permanent teeth

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Angle’s Classification

Class I is Normal

Class II

Class III

Occlusal Relationship

Normal relationships •  over jet 2mm •  over bite 2mm •  Freeway space 2 to 3 mm Abnormal relationships •  cross bite •  open bite •  quadrant of missing teeth Angle’s Classification •  Class I (normal) 1st molar mandibular and maxillary arch vertical •  Class II 1st molar mandibular posterior to maxilla •  Class III 1st molar mandibular anterior to maxilla

freeway space

Occlusal Relationships

open bite cross bite

excessive over jet excessive over bite

ideal frontal view ideal lateral view

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Occlusal Dysharmony

1. Gross loss of distal teeth

5. Degenerative changes TMJ

4. Abnormal load 3. Stretch joint structures beyond physiological limit

2. Over contraction of

elevator muscles

Occlusal Dysharmony

1. Premature Occlusal Contact

3. Develop Painful

Trigger Points

2. Hyperactivity masseter, anterior temporalis,

lateral pterygoid

Mandibular Movement Patterns

Frontal Plane •  Jerkey open or closing •  “S” deviation >2mm •  Lateral deviation >2mm Sagittal Plane •  Protrusive during

speech •  Avoidance of movement

during speech

Locking – open, close Clicking – open, close reproducible, reciprocal Crepitus – course, fine

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Mandibular Movement Patterns

< 30 mm

Acute Lock Or

Traumatic Arthritis 40 mm

Chronic Lock Capsular restriction

Intraarticular adhesion

Disc Subluxation reduction

Mm incoordination, Asymetry mov’t disc,

Hypermobility, Change in joint hydrolics

Adhesions, degenerative joint disease

Active Range of Motion

Opening Laterotrusion

Active Range of Motion

Retrusion Protrusion

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Measure is between 11 and 12 mm 11.4 mm

Find the most parallel line

Normal Values

Functional Opening

40.0 mm 2.5 mm rot 1.5 mm translation

Maximal Open 50.0 mm Ratio 4: 1: 1

Protrusion 9.0 mm

Laterotrusion 9.0 mm

Retrusion 1-2 mm

Normal Values

Young (17 – 25) Old (50-65) Male Female Male Female

Open 60.7(6.3) 57.0(4.8) 57.9(5.8) 50.5(6.6)

Protrusion 6.8(2.9) 5.3(1.6) 4.7(2.3) 4.0(2.3)

R Latero 9.9(2.7) 9.2(1.8) 7.0(2.6) 8.5(2.3)

L Latero 8.5(2.3) 8.4(1.6) 7.8(2.2) 6.3(1.6

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Passive Mobility Testing: Opening

Laterotrusion

Protrusion

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Static Muscle Testing

•  Opening •  Protrusion •  Retrusion •  Right Laterotrusion •  Left Laterotrusion

Accessary Movements

•  Caudal Distraction

•  Distraction, Retrusion

Accessary Movements

•  Compression

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Temporomandibular Disorders

Anita Gross McMaster University,

Hamilton, CA ���

TREATMENT OPTIONS Part 4

Physiotherapy Treatment for pain relief •  mobilizations for pain (grade II, III) •  soft tissue techniques (massage, trigger point release) •  modalities (ice/heat, ultrasound, acup, TENS, IF) for promoting healing •  laser •  ultra sound •  electromagnetic field therapy (EMF) for tissue prep for exercise • hydrotherapy, heat (hot pack), infrared light

trigger point desensitization • spray and stretch • acupuncture • non-invasive electronic acupuncture, IMS

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Physiotherapy Treatment for muscle strengthening & postural correction •  exercises for stiffness •  TMJ mobilizations (intra-oral or extra-oral) •  soft tissue techniques •  stretching for hypermobility •  stabilization exercises, postural correction

for neuromuscular control •  for incoordination - Internal Derangement:

–  controlled opening exercises –  stabilization exercises –  coordination exercises

•  biofeedback (relaxation, control of muscles) •  use of dental appliance/splint, as prescribed

(optimal occlusion, muscle relaxation) •  stress management techniques for cervical dysfunction •  mobilization & exercise

Physiotherapy Treatment

Manual Therapy

•  Caudal Distraction

•  Distraction, Retrusion

•  Caudal Distraction, Retrusion, rotation AP axis

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•  Ventral •  Anterior inferior glide

•  Extra Oral Techniques -  Tongue blades

-  Distraction -  Lateral glide

Manual Therapy

•  Soft tissue techniques •  acupressure •  deep friction •  massage

View youtube http://www.youtube.com/watch?v=T0EJLP69Osk&feature=related

•  Neuromuscular stabilization

Manual Therapy

TMJ Exercise

•  Gentle ROM •  Stretching •  Self mobilization •  Stabilization and strengthening

–  Isometric, isokinetic –  therabite, endurance training

•  Coordination - Proprioception

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TMJ Exercise •  Gentle ROM •  Stretches

TMJ Exercise •  Self mobilization

TMJ Exercise

•  Stabilization and strengthening –  Isometric, isokinetic –  therabite, endurance training

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Rocabado Disc Remodeling Technique

•  Goals –  Remodel disc –  Try to make the click

occur early in protrusion •  Only used when click in

active protrusion

–  Late clicks will take longer/may never fully recover

–  May be in this phase for 6-8 months

Disc Remodeling Technique

•  Protrude-> bite (hold 6 secs x 6 reps) – Can be w-months

•  Protrude->bite-retrude (hold 6 secs x 6 reps) •  Laterotrusion -> bite (hold 6 secs x 6 reps) •  Laterotrusion -> bite-return to neutral Start with small tube, progress to larger (to increase compression forces)

TMJ Exercise •  Coordination - Proprioception

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EBP: Physiotherapy

•  Active exercise & mobilizations may be effective •  Relationship b/w FHP & TMD exists •  Postural Rx useful with other techniques •  Relaxation/BF programs may be more effective

than placebo •  Combined exercise, mobilizations, posture and

relax may be effective (vs. separate Rx) (Am.J.Phys.Ther., 2006)

EBP: Splint Therapy

•  20 RCTs on splint therapy vs. other approaches (acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises, non-occluding appliance, no treatment)

•  NSD of splint vs other Rx in reducing symptoms

•  Weak evidence suggests splints effective in reducing pain severity at rest, vs no Rx

Relaxation

•  stress management programs • physical relaxation

• Occlusal Splint • Orthodontics • Surgery

Other Interventions