BRYAN LANGWHOLE BODY HEALTH PHYSICAL THERAPY

Temporomandibular Joint Disorder and Conservative

Treatment

Anatomy

Bones Mandible Cranium

Articulations Mandibular fossa of the temporal bone and the

condyle of the mandible; creating a synovial joint.Ligaments

The fibrous capsule, lateral ligament, sphenomandibular ligament, stylomandibular ligament, and mandibular-malleolus ligament.

Anatomy

Disc Fibrocartilage

Innervation Mandibular branch of the trigeminal nerve

Auriculotemporal nerve Masseteric nerve

Muscles Lateral Pterygoid Masseter Medial Pterygoid Temporalis

Blood Supply Superior temporal artery of the external carotid artery

The Tempomandibular Joint

The disc divides the TMJ into two cavities The upper synovial cavity The Lower synovial cavity

Lower Joint Compartment Formed my mandible and the articular disc Rotational movement

Upper Joint Compartment Formed by the articular disc and the temporal bone Translational movement

Therefore, there is a rotation and translation of movement with the TMJ

Biomechanics

Osteokinematics: Depression Elevation Protrusion Retrusion Lateral excursion

Open and Closed Packed Position

Open Packed of TMJ: Mouth slightly open

Closed Packed of TMJ: Mouth closed the the teeth clenched

TMJ Use

Talking Males: 12,000 words per day Females: 50,000 words per day

Swallowing Saliva 600 times daily

60 lbs of force associated with each swallow Bruxing may increase the force level to 250 lbs

Tempomandibular Disorder (TMD)

TMD = Any problem concerning the jaw jointAge: 20-40 yearsGender: Woman>MenPrevalence: 30 million AmericansIncidence: 1 million new patients every year

Pain Generating Structures

Myogenic Lateral Pterygoid Masseter Medial Pterygoid Temporalis

Arthrogenic Synovitis Retrodiscal tissue Capsule ligaments Disc (peripheral region)

TMJ Pain

Four Main Causes: Myofascial pain dysfunction syndrome Internal derangements Degenerative joint disease Temporal arteritis

Muscle Pain Maps

TMJ Dysfunction

Anterior Disc Displacement With Reduction

Anterior Disc Displacement without Reduction

Disc can displace anterior, medial, lateral, posterior or a combo (anteromedial)

TMJ Dysfunction

How does TMJ Dysfunction Occur?

1. Birth-related forceps delivery and congenital weakness of the articular ligaments

2. Traumatogenic3. Iatrogenic

a. Prolonged dental procedures b. Traumatic dental extractions c. Injudicious use of mouth prop d. Manipulation under general anesthesia e. Improper use of laryngoscope or bronchoscope

How Does TMJ Dysfunction Occur?

4. Drug: Reserpine and phenothiazines.5. Physiologic: a. Yawning. b. Sneezing. c.

Extreme opening6. Systemic: Epilepsy and other involuntary

muscle contractions.7. Long-term over-closures secondary to loss

of dentition as a result of loosening of the joint capsule

Evaluation of TMJ

Subjective Headache or maxillofacial, cervicogenic, or shoulder

pain Reports of clicking or popping Increased life-stressors

Observation Forward head and rounded shoulders Scoliosis Mouth movement with speaking Frenulum, lips, tongue scalloping, clench lines

Evaluation

Active motion Mandibular opening (40 mm) Lateral deviation (1 tooth wide, 8mm) Mandibular protrusion/retrusion Teeth clenching

Passive motion Vertical opening Lateral movements Retraction Protraction

Resisted motion (tested in neutral)

Evaluation

Palpation Crepitation, grinding, and clicking with movement Temporalis muscle Medial/lateral pterygoid muscle Anterior/posterior digastric muscle Masseter muscle

Neurological Tests Sensation Reflexes

ALWAYS ASSESS THE C/S, T/S, and SHOULDER

What We Look For

Movement Dysfunction “S” or “C” curve Asymmetrical movement Opening and translation Lateral deviation with protrusion and retrusion

Pearls of Wisdom

Cardinal Signs Unilateral joint movement Muscle tenderness A clicking and popping noise in the TMJ Limitation and/or deviation of mandibular movement.

Pearls of Wisdom

Hyperactivity or a trigger point can interfere with eccentric contraction of the lateral pterygoid muscle as it guides the disk to its resting position during mandibular closing.

Joint clicking is indicative of sliding anterior or posterior to the disc, where as crepitus us a result of degenerative joint disease or a perforation of the disc.

Therapy Modalities

Hot and cold packsVapocoolant sprayShort-wave diathermyCold laserIontophoresisJoint mobilizationsSoft tissue mobilizationExerciseEducation

Examples of TMJ Exercises

Resisted Protrusion Mandibular Opening without anterior translation

Resisted lateral excursion

Education on Proper TMJ Habits

Avoid isometric parafunctional muscle activation Clenching and chewing on pencils, pens, and

fingernailsAvoid wide moth opening greater than 3

finger widthsAvoid hard food, and cut hard and tough food

into smaller piecesChew evenly on both sides with the back

molarsUnilateral chewing on the involved sided may

be less painful because of less joint compression

Education on Proper TMJ Habits

Maintain a neutral posture of the head and neck to promote a neutral position of the mandible when chewing

Avoid a side-lying sleeping position if lateral shear of the TMJ is problematic

Hold the mandible in the resting zone to reduce activity of the masticator muscles

Avoid a forward head postureAvoid movements that produce clicking or

locking

Education on Proper TMJ Habits

Address malocclusion with dental intervention

Avoid the rest position of the tongue thrust forward, which causes protrusion of the mandible

Sleep

Sleep is essential for health The body physically renews during sleep, thus

protecting human beings from the natural wear that occurs when they are awake.

A large number of cerebral and organismal functions are influenced by sleep, as the conditions of the brain during the preceding period of wakefulness are reestablished during sleep.

Sleep

The most common causes of sleep problems: Excessive work Family responsibilities Medication use Environmental factors that harm both the quantity

and quality of sleep Changes in sleep patterns can lead to

reduced cognitive function, increased reaction time, memory loss, increased irritability and metabolic, endocrine and cardiovascular changes.

Sleeping and TMJ Disorder

The prevalence of sleep disorders and TMD in the general population is high.

Many studies have correlated poor sleep quality with chronic pain, episodes of severe pain, psychological stress and lower perceptions of self-care.

Ways to Decrease Stress

30/30 ruleMindful Based Stress Reduction

“Take 5”Jocobson relaxation technique (progressive

muscle relaxation)Exercise

Progressive Muscle Relaxation

Does PT Help?

McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther. 2006;86:710–725.  Systematic Review of literature

36 relevant articles, 12 met inclusion criteria, 3 were considered strong methodological quality Postural training, manual therapy, and exercise

all demonstrated significant benefit. Active and passive oral exercises to improve

posture are effective interventions to reduce symptoms associated with TMD.

Does PT Help?

Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther.2006;86:955–973. Systematic Review

Active exercises and manual mobilizations may be effective as well as postural training in combination with other TMD interventions.

Review favored multifaceted treatment strategies.

Does PT Help

Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed-lock. J Dent Res.2007;86:58–63. 

Ismail F, Demling A, Hessling K, Fink M, Stiesch-Scholz M. Short-term efficacy of physical therapy compared to splint therapy in treatment of arthrogenous TMD. J Oral Rehabil. 2007;34:807–817. 

de Felicio CM, Freitas RL, Bataglion C. The effects of orofacial myofunctional therapy combined with an occlusal splint on signs and symptoms in a man with TMD-hypermobility: Case study. Int J Orofacial Myology. 2007;33:21–29.

Monaco A, Cozzolino V, Catteneo R, Cutilli T, Spadaro A. Osteopathic manipulative treatment (OMT) effects on mandibular kinetics: Kinesiographic study. Eur J Paediatr Dent. 2008;9:37–42. 

Does PT Help

Conclusion summary of the 4 articlesIn general, the validity and strength of the

studies were weak. However, all evidence continued to support the

statement that physical therapy may be an effective stand-alone therapy.

It is more effective when combined with a team approach with other conservative TMD therapies.

Future Physical Therapy Intervention?

Dr. Rocabado rollback technique Recapturing the articular disc

Interdisciplinary Approach

Dentistry Interventions to TMJD

Occlusal orthotic Beneficial for:

masticatory muscle pain, TMJ pain, TMJ noises, restricted jaw mobility, and TMJ dislocation

If the patient’s pain is limited to the masticatory system with minimal psychosocial contributors, symptoms can be reduced without referral.

Common modes of action for splints All decrease occlusal forces All will have a placebo effect (cognitive awareness) All will alter occlusal contacts

Main Types of Splints

The soft vacuum-formed splint (soft bite guard) Most commonly prescribed splint Good for quick fabrication for emergency TMD Usually made for lower arch Not easily adjustable Worn at night If successful, reproduce symptomatic relief within 6

weeks

Main Types of Splints

The localized occlusal interference splint Indicated for a pt who shows active signs of bruxism

(cheek ridging and tongue scalloping) “The habit breaker” The device restricts the teeth from touching during

closure Forces on the proprioceptive fibers discourage

clenching Effective for patients who parafunction in centric

occlusion Not successful for those who parafunction in extreme

excursive positions Used at night or when pt notices parafunction (ex

driving)

Main Types of Splints

The anterior repositioning splint For disc displacement with reduction Full coverage splint on the lower arch Identified as beneficial if click disappears if

opening/closing from protruded position Guides mandible downward and forward in a protruded

position Theory: If mandible is protruded, condyle is downward

and forward. This temporarily restores normal relationship with the displaced intra-articular disc

Pts wear splints at all times, 24 hours a day -- even when eating

3 months of wear with a careful weaning period

Main Types of Splints

The stabilization splint For patients with facial arthromyalgia where a

discrepancy between centric occlusions and centric relation is the aetiological factor

Names for splint: Tanner appliance, Fox appliance, Michigan splint, centric appliance

Fitted to either the upper for lower jaw The point is to stabilize the mandible against the

maxilla Time consuming to create and can take up to an hour

to fit/adjust Should be word at night

Surgical Modalities

Condylectomy Indicated for fibrous ankylosis Excision of the condyle and removal of fibrous bands which

are restricting the movementsGaparthroplasty

Provides a gap between the glenoid fossa and the ramus of the mandible

Interpositional athroplasty with costochondral graft Creation of a gap and placement of a barrier to maintain

vertical height of the ramusAthroscopyTMJ Replacement

Surgical Interventions

Capsule tightening procedure a. Chemical capsulorrhaphy b. Surgical capsulorrhaphy: Tightening the capsule by

suturesLateral pterygoid myotomyPlication of TM joint ligaments Raising the height of the articular eminence

by down fracture of the zygomatic boneEminectomy and meniscectomy

Surgical Intervention

Arthrocentesis and lavage Has been shown to be an effective technique for the

treatment of acute persistent closed lock of the TMJ Can be done under general anesthesia with two

hypodermic needles Usually the first surgical operation performed Can be helpful if disc is adhered to the bone

When to Refer to PT?

Mechanism Situation

Cervical The patient has neck pain worth of treatment.

The patient has cervicogenic headaches (headaches that can be reproduced by palpating the neck).

Postural The patient has moderate to severe forward head posture.

The patient’s TMD symptoms increase with abnormal postural activities.

The patient desires help in changing poor sleeping posture (e.g., stomach sleeping).

OutcomeOriented

The patient is to have TMJ surgery; patients who receive physical therapy after TMJ surgery may have significantly better results. It is appropriate to refer these patients to PT prior to surgery.

When Does PT Refer to Dentistry?

Time Factor

Event Treatment

Nocturnal The patient awakes with TMD Pain

Improve sleep positions

Occlusal orthotics at night

Prescribe meds that decrease EMG activity

Relaxation prior to sleep

Daytime The patient has symptoms associated with tooth related pain such as

Comprehensive dental examination and treatment

• Pain occurs or intensifies upon drinking hot or cold beverages

• Throbbing pain occurs spontaneously

• Throbbing pain awakes him/her from sleep (there can be other causes for this)

Multidisciplinary Treatment Approach

Orientation Treatment

Relaxation/Stress Management

Breaking daytime parafunction muscle-tensing habits

Learning to relax masticatory muscles and maintaining this relaxed state throughout the day

Learning stress management and coping skills for life’s irritations

Performing biofeedback to help learn to relax masticatory muscles

Orthotic Wearing an occlusal orthotic during the day (as a temporary crutch until daytime habits are broken)

Medicative Prescribing a tricyclic antidepressant that can be taken during the day (e.g. desipramine (25 mg, 1 tab in the morning and afternoon)

Multidisciplinary Treatment Approach Cont.

Orientation Treatment

Medicative Prescribing NSAIDs and/or steroids

Passive Approach Physical therapy modalities (heat, ice, ultrasound, laser, iontophoresis)

Performing jaw-stretching exercises

Active Approach Performing head and neck posture improvement exercises

Indirect Approach

Performing cervical therapist (manual techniques, neuromuscular re-education, etc.)

Questions?

References

Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2003). Mindfulness-based Stress Reduction And Health BenefitsA Meta-analysis. Journal of Psychosomatic Research, 57(1), 35-43.

Gray, R., & Davies, S. (2001). Occlusal Splints and Temporomandibular Disorders: Why, When, How? Dental Update, 28, 194-199.

Murakami, K., Hosaka, H., Moriya, Y., Segami, N., & Iizuka, T. (n.d.). Short-term treatment outcome study for the management of temporomandibular joint closed lock. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 80(3), 253-257. Retrieved April 2, 2015, from http://www.oooojournal.net/article/S1079-2104(05)80379-8/abstract

Medeiros Veiga, D., Cunali, R., Bonotto, D., & Afonso Cunali, P. (n.d.). Sleep quality in patients with temporomandibular disorder: A systematic review. Sleep Science, 6(3), 120-124. Retrieved from http://www.sleepscience.com.br/pdf/articles/vol6/SleepScience_vol6_Issue03_art06.pdf

McNeely, M., Olivo, S., & Magee, D. (2006). A systematic review of the effectiveness of physical therapy interventions for tempomandibular disorders. Physical Therapy, 86(5), 710-725.

References

Rocabado, M. (1982). Physical Therapy for the Postsurgical TMJ Patient. Journal of Craniomandibular Disorders: Facial and Oral Pain, 3, 75-82.

TM Joint and Its Diseases. (n.d.). Retrieved April 2, 2015, from http://www.jaypeedigital.com/books/9788180616372/Chapter wise Pdf/10149/Chapter-07_TM Joint and Its Diseases.pdf

Temporo-Mandibular Joint Complex Exercise Suggestions. (n.d.). Retrieved April 2, 2015, from http://www.exodontia.info/files/Temporo-Mandibular_Joint_Complex_Exercise_Suggestions.pdf

Wright, E., & North, S. (2009). Management And Treatment Of Temporomandibular Disorders: A Clinical Perspective. Journal of Manual & Manipulative Therapy, 17(4), 247-254.

Weber, K. (2007, January 1). Standard of Care: Temporomandibular Joint Disorder. Retrieved April 2, 2015, from http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical therapy standards of care and protocols/tmj disorder.pdf