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Temporomandibular Joint Assessment and Treatment

Kristen Faiola, SPT

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Anatomy review

Masseter:

zygomatic arch → ramus of mandible

Closes and ipsilaterally

deviates jaw

Temporalis:

temporal fossa → coronoid process of mandible

Closes and ipsilaterally deviates jaw

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Anatomy review

Lateral Ptyergoid:

Sphenoid → mandibular condyle & disc

Opens and protracts jaw
Contralateral deviation

Medial Ptyergoid:

Lateral Ptyergoid plate → medial angle of mandible

Closes and protracts jaw
Contralateral deviation

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Anatomy review

Accessory musculature:

Infrahyoid muscles
Suprahyoid muscles
STM
Upper Trapezius
Suboccipitals

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Anatomy review

Joint Space

Synovial condylar modified ovoid, hinge- type joint

Articular disc separates the joint into 2 cavities

Superior cavity and Inferior cavity

These cavities plus the teeth = trijoint complex

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Anatomy review

Joint Space

Superior Cavity:

Gliding and translation

Inferior Cavity:

Rotation and hinge

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Anatomy review

Joint Space

Resting Position: With lips closed, teeth slightly apart

Closed packed position: jaw fully opened or fully closed

Capsular pattern: limitation of mouth opening

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Anatomy review

Joint Arthrokinematics

During Mouth Opening

Early phase - 25mm

Roll posterior, slight glide anterior

Late phase - next 10/15mm

Glide anterior, slight roll posterior
The disc is rotated posteriorly on the condyle as the condyle is translated out of the mandibular fossa

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Orofacial Pain
Headaches
Restricted Jaw Motion
Painful joint Noise (Clicking)

Common Complaints

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Headaches

Could be :

TMJ referred pain
Temporalis muscle tightness
Cervical Spine (cervicogenic)

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Painful Joint Noise

Can result from disc displacement or adhesions

Adhesions: result from Bruxism

Clicking noted after release of prolonged jaw clenching

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Functional Outcome Tools

TMJ Scale

TMD Disability Index Questionnaire

Assessment

Rehab measures

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Predisposing Factors

Forward head posture
Female > male x4
Malocclusion
Stress
Trauma
Sinus problems

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Forward Head Posture

Allows passive tension of the Supra and Infrahyoid musculature
This in turn, alters the resting position of the mandible

Inferiorly and posteriorly = more compression

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Forward Head Posture

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Stress

�Stress, anxiety, and depression serve to maintain TMD; therefore is best approached as a biopsychosocial dysfunction.

Bruxism: multiple studies link association between stress / anxiety and bruxism

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Stress

Augusto, et. al - 2016

More frequent among women (76.4%).
The prevalence of TMD in the sample was 71.9%;

Light TMD = 50%
Moderate = 16.4%
Severe = 5.5%

The average perceived stress was 30.9 / 50

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Stress

Oliveira, et. al - 2016

Pt population : 160 Nurses

Increased severity of TMD correlated with poorer sleep quality
Quality of life decreased as TMD severity increased
Trait anxiety was associated with presence of TMD, and state anxiety was associated with TMD severity

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Clinical impairments

Limited ROM
Postural abnormalities
Abnormal joint sounds
TTP over joint and associated musculature
Abnormal tone of associated musculature
Abnormal tracking of mandible

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ROM Norms

Mouth Opening: Middle of upper teeth → top of lower teeth

40mm (about 2 knuckles)

Four knuckles considered hypermobile

Lateral deviation: midline of upper teeth → midline of lower

8 - 10mm

Protrusion: top teeth → lower teeth

6 - 9mm

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MMT / Resisted Tests

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Joint Mobility

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Special Tests

Forced Compression (Retrusion) Provocation

Positive = Pain Provocation

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Special Tests

Biting Force Provocation

Positive = Pain Provocation

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Reflex Test

Place thumb on Pt’s chin
Examinter taps their thumbnail with reflex hammer

Reflex: Mouth closing - CN V Trigeminal

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Dysfunction Classification

Osteoarthritic changes in joint
Subluxation of the articular disc
Muscle guarding of masticatory musculature

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TMD Classification

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Joint Hypermobility

Posterior ligament and collateral ligaments lose ability to stabilize the articular disc

lateral ptyergoid pulls disc anteromedially

Progressive hypermobility may cause disc dislocation

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Disc Displacement

Anterior Disc Displacement with Reduction

�Spasm of the lateral pterygoid can pull the disc anteriorly.
Click noted at opening

and closing of jaw

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Disc Displacement

Disc Displacement without Reduction

Limitations in mouth opening due to “locked” anterior displacement of disc
Articular disc limits the

amount of translation

(no clicking)

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Joint mobility
Modalities
Cervical/ Thoracic corrections
STM
Therapeutic exercise
Surgery

Treatment

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Multidisciplinary Approach

Stress management

Physical Therapy

Dentist / Orthodontist

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Joint Splinting

Michigan Splint - April 2018

Only worn at night.
after successful splint therapy (normally between two to three months), patients can be weaned off the splint
long-term effects: after 1 year only 27.6% of patients reports “very good” treatment effects

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Joint Mobility

Distraction Anterior Glide

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Joint Mobility

Medial Glide Lateral Glide

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Modalities

US / ESTIM - April 2018

ultrasound group showed a higher success rate (93.3% pain improvement) than the TENS group (success rate of 53.3%).
concluded that ultrasound is most successful in alleviating muscle symptoms and less effective in reducing symptoms associated with the disc

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Modalities

Laser Therapy - May 2018

A Systematic review containing 31 RCTs.
Results suggest that LLLT effectively relieves pain and improves functional outcomes in patients with TMD.

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Modalities

BIOFEEDBACK - December 2013

85 Pt’s with chronic TMD for 8 weeks
Significant reductions in pain intensity and disability
Significantly larger improvements in pain coping skills
Significantly high satisfaction of treatment and ratings of improvement
Effects were stable over 6 months

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Cervical / Thoracic

Postural Training / Awareness

Cervical retractions
Scapular retractions
Thoracic extensions
Stretching
Strengthening

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Soft tissue

Gomes, et. al - March 2014

Massage therapy ( x 4 weeks) on the masticatory muscles lead to an increase in mandibular ROM

maximum active mouth opening and B lateral excursion

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Rocabado Exercises

Mariano Rocabado, PT - Chile

Exercise program tailored to address

postural relationships between TMJ, neck, and head
Proper control of masticatory musculature

Exercises to be completed 6X per day

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Rocabado Exercises

Mariano Rocabado, PT - Chile

Nasal breathing in resting position
Controlled mouth opening
Rhythmic stabilization
Stabilized head flexion
Axial extension
Shoulder retraction

EXPLAIN EACH!!

Avoid straining the jaw:

1. Avoid wide opening or yawning. Avoid clicking of the jaw or causing the jaw to get locked.

2. Use softer, mushy, pureed foods and non-chew foods such as pudding, yogurt, soups or omelets. No hard crunchy and chew foods like raw carrots, granola bars, steak, etc…

3. No clenching or grinding of the teeth during the day. Make yourself aware of where your jaw is at all times. The teeth should not touch except when chewing.

4. Avoid chewing gum, nail and cuticle biting, crushing ice cubes, playing wind musical instruments or moving the jaw in weird and different positions.

5. Avoid long dental appointments with your jaw open wide or dentistry altogether until the jaw gets better. You may have to postpone dental cleanings for a while.

6. Apply ice or a moist towel warmed up in the microwave to soothe and relax the muscles. 7. Watch your posture: ie – slouching over, sitting in uncomfortable chairs, neck extensions. Avoid forward head posture activities (crafts, sewing and computer work). Take frequent breaks when working at computers, office desk, ironing etc….

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Surgery

Injections- April 2018

Intra-articular injections can stimulate regeneration and inhibit degenerative changes in the cartilage
Examples: HA, corticosteroids, Botox, and platelet-rich plasma,

Hyaluronic acid - provides a long term lubricating effect, reducing the actions of inflammatory mediators and increasing joint mobility

All Studies reported significant decreases in pain. ROM improvements were noted in most studies; however some report no significant increase in mouth opening ROM

Botox: treats bruxism (teeth grinding), myofascial pain, disorders associated with TMJ disc displacement, and habitual dislocation of the mandible (paralyzes muscle by blocking nerve endings - relaxes)

All studies reports favorable outcomes to the end of the follow up period
Botox CONTRAINDICATED to: pregnant women / breast feeding women or during infection / active inflammation of area.

Abouelhuda AM, khalifa AK, Kim Y-K, Hegazy SA. Non-invasive different modalities of treatment for temporomandibular disorders: review of literature. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2018;44(2):43-51. doi:10.5125/jkaoms.2018.44.2.43.

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Surgery

Arthrocentesis- April 2018

High success rates have been reported for internal derangements

effectiveness is temporary; it does not rehabilitate the microarchitecture of the TMJ.

typically with addition of HA injection

arthrocentesis plus HA injection is superior to arthrocentesis alone

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Surgery

TMJ Arthroscopy- April 2018

Posterior repositioning of articular disc
55% decrease in pain level and 34% increase in maximum mouth opening

found that patients with a shorter duration of symptoms benefited more than those with a longer duration.

Patients in the early to intermediate stage had excellent results in 94% of cases.

Several studies demonstrating the efficacy of TMJ arthroscopy have been published.

In a multicenter study involving 6 years follow and 4,831 joints, patients responded very well to TMJ arthroscopy for various forms of ID.
TMJ arthroscopic lysis and lavage was specifically successful in intermediate and intermediate/late progression of ID (Wilkes stages III and IV),
average 90% success rate with arthroscopic lysis and lavage in a 5-year follow-up study.

Abouelhuda AM, khalifa AK, Kim Y-K, Hegazy SA. Non-invasive different modalities of treatment for temporomandibular disorders: review of literature. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2018;44(2):43-51. doi:10.5125/jkaoms.2018.44.2.43.

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Surgery

TMJ Arthroplasty- 2015

25 year follow up for TMJ IC arthroplasty
352 Pt’s treated for total of 696 involved joints

Results:

VAS pre surgery : Avg 58.3 Post surgery: Avg 7.7

VAS Pre (Cervical): Avg 47.7 Post Surgery: Avg 16.7

Surgery generally not recommended in the past, unfavorable outcome only 50% reported favorable outcome at 6 months post-op

However recent studies (past 5 years) have found favorable outcomes with surgical intervention of TMJ
Study from 2009 Cascone P, Ramieri V, Arangio P, Vellone V, Tarsitano A, Marchetti C. TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty). Annali di Stomatologia. 2016;7(3):60-64. doi:10.11138/ads/2016.7.3.060.

TMJ inferior compartment arthroplasty procedure through 25-year follow-up (functional arthroplasty)

IC = inferior compartment

Specific for Wilkes classification for internal derangement classification 2

VAS scale used was 0 - 100

2nd VAS = heachache and cervical pain VAS

Results were maintained over the 25 years - reason for calling functional arthroplasty (good lasting results)

Numerous recent studies has also found favorable outcomes following Arthroplasty

Cascone P, Ramieri V, Arangio P, Vellone V, Tarsitano A, Marchetti C. TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty). Annali di Stomatologia. 2016;7(3):60-64. doi:10.11138/ads/2016.7.3.060.

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Questions?

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References

Magee DJ. Orthopedic Physical Assessment. 6th ed. Vancouver, B.C.: Langara College; 2017.

TMJ Scale. Shirley Ryan AbilityLab - Formerly RIC. https://www.sralab.org/rehabilitation-measures/tmj-scale. Published September 2015. Accessed July 2018.

Alves AC, Alchieri JC, Barbosa GA. Bruxism. Masticatory implications and anxiety. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/24294819. Published 2013. Accessed July 2018.

Augusto VG, Perina KCB, Penha DSG, dos Santos DCA, Oliveira VAS. TEMPOROMANDIBULAR DYSFUNCTION, STRESS AND COMMON MENTAL DISORDER IN UNIVERSITY STUDENTS. Acta Ortopedica Brasileira. 2016;24(6):330-333. doi:10.1590/1413-785220162406162873.

OLIVEIRA, Larissa Kattiney, ALMEIDA, Guilherme de Araújo, LELIS, Éverton Ribeiro, TAVARES, Marcelo, & FERNANDES NETO, Alfredo Júlio. (2015). Temporomandibular disorder and anxiety, quality of sleep, and quality of life in nursing professionals. Brazilian Oral Research, 29(1), 1-7. Epub June 02, 2015.https://dx.doi.org/10.1590/1807-3107BOR-2015.vol29.0070

Olson KA. Manual Physical Therapy of the Spine. St. Louis, MO: Elsevier; 2016.

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References

Abouelhuda AM, khalifa AK, Kim Y-K, Hegazy SA. Non-invasive different modalities of treatment for temporomandibular disorders: review of literature. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2018;44(2):43-51. doi:10.5125/jkaoms.2018.44.2.43.

Melis M, Giosia MD, Zawawi KH. Low Level Laser Therapy for the Treatment of Temporomandibular Disorders: A Systematic Review of the Literature. Cranio®. 2018;30(4):304-312. doi:10.1179/crn.2012.045.

Biofeedback-based Cognitive-Behavioral Treatment Compared With Occlusal Splint for Temporomandibular Disorder: A Randomized Controlled Trial. Medicine & Science in Sports & Exercise. https://insights.ovid.com/pubmed?pmid=23446073. Published 2013. Accessed July 2018.

Cid André Fidelis De Paula Gomes, Politti F, Andrade DV, et al. Effects of Massage Therapy and Occlusal Splint Therapy on Mandibular Range of Motion in Individuals With Temporomandibular Disorder: A Randomized Clinical Trial. Journal of Manipulative and Physiological Therapeutics. 2014;37(3):164-169. doi:10.1016/j.jmpt.2013.12.007

.Cascone P, Ramieri V, Arangio P, Vellone V, Tarsitano A, Marchetti C. TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty). Annali di Stomatologia. 2016;7(3):60-64. doi:10.11138/ads/2016.7.3.060.